Clinical Examination of Respiratory Conditions

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Questions and Answers

What condition is associated with increased vocal fremitus due to transmission through a dense medium?

Bronchial obstruction

Pleural effusion

Consolidation (correct)

Obesity

In the presence of a pneumothorax, which of the following findings would be expected upon inspection?

Hyper-resonant percussion note

Increased chest movement on the affected side

Diminished breath sounds

Diminished chest movements on the affected side (correct)

What test involves asking a patient to whisper while auscultating the lung fields?

Whispering pectoriloquy (correct)

Egophony

Tactile fremitus

Bronchophony

What is the expected percussion note on the affected side in a pleural effusion?

Stony dullness Signup and view all the answers

Which of the following is NOT a characteristic finding in a patient with emphysema/COPD?

Increased chest resonance Signup and view all the answers

What is a typical finding during palpation in the examination of a patient with pleural effusion?

Diminished vocal fremitus Signup and view all the answers

Which of these changes in vocal resonance is characterized by a louder sound over an area of consolidation?

Bronchophony Signup and view all the answers

Which condition is characterized by a qualitative change in voice, where 'E' is perceived as 'A'?

Egophony Signup and view all the answers

Which of the following aspects should be prioritized during the initial on-field assessment of a concussion?

Assessing cognitive function and balance Signup and view all the answers

What is likely the main goal during the management of a concussion regarding return to activity?

To implement a gradual return to activity tailored to the individual's recovery. Signup and view all the answers

In the context of clinical evaluation of musculoskeletal disorders, which examination would most likely reveal issues related to joint mobility in the knee?

Knee Examination Signup and view all the answers

In evaluating Metatarsus Adductus (MTA), which of the following factors is considered a significant risk indicator?

History of familial genetic predisposition Signup and view all the answers

Which of the following best describes an important preventative strategy against concussions?

Implementing proper techniques in contact sports Signup and view all the answers

What does increased vocal fremitus suggest in a clinical assessment of a respiratory condition?

Pneumonia Signup and view all the answers

Which physical examination finding is most commonly associated with pleural effusion?

Dullness on percussion Signup and view all the answers

What symptom would most likely indicate the presence of left-sided heart failure?

Dry cough during the night Signup and view all the answers

Which physical examination finding is indicative of consolidation in the lungs?

Increased vocal resonance Signup and view all the answers

What does a positive hepatojugular reflex indicate?

Fluid overload or congestive heart failure Signup and view all the answers

Which of the following conditions is characterized by diminished breath sounds and vocal resonance?

Pleural effusion Signup and view all the answers

In the context of heart failure, what does the presence of crackles (rales) suggest?

Fluid accumulation in the lungs Signup and view all the answers

Which symptom would most likely lead a clinician to suspect bronchial obstruction?

Wheezing Signup and view all the answers

Which of the following conditions is least likely to be diagnosed primarily through a clinical examination?

Gastroesophageal reflux disease (GERD) Signup and view all the answers

Which clinical finding is NOT typically associated with elevated filling pressures in heart failure patients?

Pulmonary rales Signup and view all the answers

What percentage of heart murmurs in infants are associated with congenital heart disease?

37% Signup and view all the answers

Which of the following statements regarding heart failure management is accurate?

Symptom assessment via the clinical exam is crucial for managing heart failure. Signup and view all the answers

Which assessment method is recommended for evaluating the likelihood of a pulmonary embolism?

Wells criteria or PERC Signup and view all the answers

Which symptom is classified as bendopnea in heart failure patients?

Shortness of breath when bending forward Signup and view all the answers

What is the primary focus of the emerging classification system for heart failure congestion?

Evaluating right-sided versus left-sided ventricular filling pressures Signup and view all the answers

Why is it essential to screen all infants for critical congenital heart disease?

Early detection can lead to timely interventions. Signup and view all the answers

What is the typical presentation of Slipped Capital Femoral Epiphysis (SCFE)?

Hip, knee, or thigh pain with decreased internal rotation Signup and view all the answers

When is surgical fixation urgently required in SCFE cases?

With persistent hip pain and displacement observed on imaging Signup and view all the answers

At which degree of spinal curvature is MRI indicated for scoliosis evaluation?

Atypical curves or early-onset scoliosis Signup and view all the answers

What is the recommended screening procedure for Developmental Dysplasia of the Hip (DDH) in high-risk infants?

Ultrasound screening at 4-6 weeks Signup and view all the answers

What is the goal of treatment for Developmental Dysplasia of the Hip (DDH)?

To maintain concentric hip reduction for normal development Signup and view all the answers

Which condition is associated with red flag symptoms indicating potential serious pathology in low back pain evaluation?

Cauda Equina Syndrome Signup and view all the answers

What is the classification of scoliosis that is most commonly seen in adolescents?

Adolescent idiopathic scoliosis Signup and view all the answers

What degree of scoliosis curvature typically requires bracing treatment?

25-40° Signup and view all the answers

Which diagnostic imaging is primarily used for diagnosing SCFE?

AP and frog-leg lateral x-rays of the pelvis Signup and view all the answers

What condition is characterized by a spinal curve greater than 10° as seen on x-ray?

Scoliosis Signup and view all the answers

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.