CMS100 Practical Exams.docx

CMS100 Practical Exams DO NOT FORGET TO SANITIZE YOUR HANDS “Hello, my name is Athena, and I am naturopathic medical student. Today I am going to be performing a series of physical exams, do I have your consent to do so?” Remain standing on the RIGHT SIDE of your patient (best for charting) Physical...

CMS100 Practical Exams DO NOT FORGET TO SANITIZE YOUR HANDS “Hello, my name is Athena, and I am naturopathic medical student. Today I am going to be performing a series of physical exams, do I have your consent to do so?” Remain standing on the RIGHT SIDE of your patient (best for charting) Physical Exam Technique What to Verbalize Pathology Dermatology Exam First, assess the skin on the scalp, parting different sections of the hair to better visualize the skin underneath. Explore the areas from the frontal region to the occiput, around the posterior neck and neckline, as well as around and behind the ears.   Next observe the skin on the face, paying attention to the areas around the eyebrows, eyes, nasolabial folds, and under the chin.  Pull the lower lids down to observe the conjunctival rim (as part of an assessment of pallor in mucous membranes) if indicated. Also examine the anterior neck, and upper shoulders to the level of the clavicles. Roll up the sleeves of the gown on both sides and expose the entire arm from the forearm to the upper arm and axillary area. Examine the dorsal and ventral surfaces of both arms, as well as the elbows, wrists, dorsal and palmar aspects of the hands, and fingers. Be careful to examine the areas between the fingers in the webs.  Note the skin around the proximal and lateral nail folds and observe the nails – shape, contour, and texture. Then ask the patient to stand and raise their gown up to mid-thigh. This will allow you to examine most of the upper leg, and lower leg, from both anterior and posterior aspects. Be careful to examine up to the ankles (medial and lateral aspects), and behind the knees. *Note upper and lower leg examination can also be completed with the patient seated (for anterior surfaces) or lying supine and prone (for anterior and posterior surfaces) with appropriate draping Ask the patient to be seated and expose the posterior thoracic region. Be sure to be able to observe the lateral aspects of the thorax and abdomen to the mid-axillary line, and from the neck to the level of L5. Nails: Inspect and palpate the fingernails and toenails. Note their color, shape, and any lesions. Longitudinal bands of pigment may be seen in the nails of healthy, darker-skinned individuals.    Here are some examples of nail signs and disorders. Try looking up some images as well for more clarity.   Inspect and palpate the skin: this includes assessment of: Skin Color: look for changes in pigmentation, redness, pallor, cyanosis and yellowing of the skin. Pallor is seen on the fingernails, lips, and mucous membranes particularly of the mouth and palpebral conjunctiva. In dark skinned individuals inspecting the palms and soles for pallor might also be useful  Central cyanosis is best identified in the lips, oral mucosa, and tongue. Be aware the darker skinned individuals have melanin in their lips that may simulate cyanosis. Cyanosis of the nails, hands and feet can be central or peripheral in origin. Jaundice (yellow colouring of skin) can be observed in the sclera, palpebral conjunctiva, lips, hard palate, undersurface of the tongue, tympanic membrane, and skin! Moisture: look for dryness, sweating and oiliness Temperature: use the backs of your hands to assess the temperature of the skin on the arms and legs. Note the temperature on any red areas. Texture: palpate the skin for any roughness or smoothness Mobility and turgor: lift a fold of skin on the dorsum of the hand, sub-clavicular fossa, or anterior thigh for 3 seconds so that it is tented and then release; observe its ability to change shape and return to normal.  In a study to assess the sensitivity and specificity of the main clinical characteristics of elderly people with hypernatremia, skin turgor was measured. Skin turgor was found to be decreased if tenting lasted > 3 seconds following 3 seconds of skin pinching. The researchers found that abnormal sub clavicular and anterior thigh skin turgor was significantly and independently associated with hypernatremia in patients. Skin Lesions: note their characteristics. Inspect and palpate the fingernails and toenails: note their colour and shape and whether any lesions are present. Skin lesions can be described in the following ways… macule, a flat, nonpalpable circumscribed area (up to 1 cm) of color change that's brown, red, white, or tan.  patch, a flat, nonpalpable lesion with changes in skin color, 1 cm or larger. papule, an elevated, palpable, firm, circumscribed lesion up to 1 cm plaque, an elevated, flat-topped, firm, rough, superficial lesion 1 cm or larger, often formed by coalescence of papules. nodule, an elevated, firm, circumscribed, palpable area larger than 0.5 cm: it's typically deeper and firmer than a papule. cyst, a nodule filled with an expressible liquid or semisolid material. vesicle, a palpable, elevated, circumscribed, superficial, fluid-filled blister up to 1 cm. bulla, a vesicle 1 cm or larger, filled with serous fluid.  pustule, which is elevated and superficial, like a vesicle, but is filled with pus. wheal, a relatively transient, elevated, irregularly shaped area of localized skin edema. Most wheals are red, pale pink, or white. scale, a thin flake of dead exfoliated epidermis. crust, the dried residue of skin exudates such as serum, pus, or blood. lichenification, visible and palpable thickening of the epidermis and roughening of the skin with increased visibility of the normal skin furrows (often from chronic rubbing) excoriation, linear or punctuate loss of epidermis, usually due to scratching.   Consider the ABCD(E) method to screen for melanoma in describing moles… A: Asymmetry B: Border – irregular C: Colour variation D: Diameter > 6mm E: Evolution/change - as part of your history/examination   Practice Question: Try to name at least 3 other descriptors you could add if you had more information from the image.     This is a melanoma. An accurate description would include: a macule/papule, asymmetrical shape, with irregular borders, brown in colour with variation of darker brown in 1/3rd of the lesion.   Match the description with the image     D: Multiple, hypopigmented macules and patches symmetrically distributed on the upper chest (or anterior thoracic) region, extending to upper arms, varying in size. This is a presentation of tinea versicolor.     B: Multiple, raised, red and scaly patches of skin on the dorsum of the right hand, extending to the fingers. Appears to have thick silvery/white dry scale, with a rough texture. This is a typical presentation of plaque psoriasis.     A: Two annular lesions on forearm, appear to be about 1cm in diameter, circular with red (erythematous), raised borders that are crusty, with central clearing. This is tinea corporis (ringworm).     C: Red (Erythematous), raised wheals on inner thigh and around the knee, asymmetrical distribution, regular borders, small wheals as well as one larger coalesced wheal. This is urticaria (hives).   Describe the image below one a piece of paper using the descriptors learned.     Note the same image up close in different skinned individuals…     Jaundice - Appearance of Yellow Sclera     Cianosis Note the differences in appearance of cyanosis in individuals of different colour of skin, as well as the areas of cyanosis on extremities (peripheral cyanosis) and lips/tongue (central cyanosis). As a fun activity try to find images of healthy individuals to compare with these images provided.    Image 1: Peripheral cyanosis   Image 2-4: Central cyanosis in different skinned individuals     Back - Jaundice – appearance of yellow sclera Blood Pressure Place deflated cuff on patient’s arm, 2.5-3 cm proximal to antecubital fossa (make sure artery marking lines up with brachial artery). Hold supinated arm at level of patient’s heart. Palpate the patient’s radial artery on the same arm. Inflate cuff slowly and note the value where the radial pulse disappears. Deflate the cuff. Get patient to raise their arm in the air and pump fist 10x. Place bell of stethoscope over brachial artery in antecubital fossa (make an air seal) Inflate cuff to a pressure 20-30 mm Hg higher than value eliminating radial pulse. Open value slightly and release pressure at rate of 2 mm Hg/sec. Listen for Korotkoff sounds (first audible at systolic pressure, disappears at the diastolic pressure) Normal: <120/80 mm Hg “I obtained a blood pressure reading of _____ mm Hg” Hypotension: low blood pressure of <90/60 mm Hg Fatigue, shortness of breath on exertion, light-headedness Most common cause is dehydration or decreased CO In those with acute illness, an SBP <90 mm Hg can predict death in hospitalized patients in the ICU, and in patients with bacteremia and pneumonia; with a SBP of <80 mm Hg it can predict death in patients with MI According to the APACHE (Acute Physiology and Chronic Health Evaluation) scoring system, it assigns more points (and thus higher risk) to severe hypertension than to any other vital sign or lab variable as predictor of hospital mortality In patients with MI, an SBP of <80 mm Hg predicts much higher incidence of congestive HF, ventricular tachycardia and fibrillation, and complete heart block Elevated: systolic of 120-129 and diastolic less than 80 Hypertension… May cause end organ damage with equally disastrous consequences These include heart attack, stroke, hypertensive renal failure, and retinopathy Stage 1: systolic of 130-139 and diastolic between 80-89 Stage 2: systolic of >140 or diastolic is >90 Temperature Just take it lol Normal temperature range varies between 36ºC-37.5ºC A fever is defined as an oral temperature greater than 37.7ºC and a temperature of more than 37.8ºC at any site Abnormal minimum temperatures are difficult to determine, as oral temperature can drop to 35ºC during sleep Heart Auscultation Lie the patient supine with butterfly drape Apply both diaphragm and bell to listen to patient’s heart sounds. Aortic (A): 2nd intercostal space on right sternal border. Pulmonic (P): 2nd intercostal space on left sternal border. Erb’s Point (E): 3rd intercostal space on left sternal border. Tricuspid (T): 4th intercostal space on left lower sternal border. Mitral (M): 5th intercostal space on midclavicular line. Remember the mnemonic “APE To Man” Timing (systolic/diastolic) Intensity (loud/soft) Duration (long/short) Pitch (high/low) Quality (musical, harsh crescendo, decrescendo…) “S1 and S2 heart sounds were clear and distinct, and there are no other extra sounds or murmurs audible to indicate pathology. We are done auscultating the heart” Third Heart Sounds: Appears in early diastole A.k.a ventricular gallop Best heart at apex (LV) or left lower sternal border (RV) of heart WITH THE BELL May only be heard in LLD position It CAN be normal in children or athletic young adults (<40 years) Occurs in (1) congestive heart failure, and (2) regurgitation/shunts) LLD = rolled onto left side Fourth Heart Sounds: Audible in late diastole A.k.a atrial gallop Best heart at apex (LV) or left lower sternal border (RV) of heart WITH THE BELL May only be heard in LLD position Right S4 gallops are louder with inspiration, while left S4 gallops are softer during inspiration Greater the flow rate, the louder the sound The stiffer the ventricle, the higher the frequency S4 is ALWAYS pathological Occurs in (1) hypertension, (2) ischemic cardiomyopathy, and (3) aortic stenosis Cardiac conditions characterized by ventricular stiffening (via hypertrophy or fibrosis) Jugular Venous Pressure Raise patient’s head so it is elevated approximately 30-45º. The top of neck veins is indicated by either the point above the external jugular veins disappears or point above which the bi-phasic pulsations of internal jugular vein become imperceptible (use penlight to assist). Measure vertical distance from top of vein and sternal angle “I see about a ____cm distance between bottom of straight edge and surface of the sternal angle, with the head elevated to approximately 30-45º.” “To this I’ll add 5cm to assess ___cm of pressure in the right atrium.” Pathologies increasing diastolic pressure of right side of heart increase central venous pressure, making neck veins visibly distended. Most helpful in patients with ascites or edema Elevated JVP indicates heart or lung disease as opposed to other causes of increases central venous pressure such as chronic liver disease. Heart Rate Use pads of first and second finger to press firmly on the radial artery. Listen for a minimum of 15 seconds, then multiple by 4 to convert to beats per minute. Pulse Amplitude: 0 = absent/not palpable 1 = difficult to palpate, thready, weak 2 = easy to palpate (normal) 3 = full, bounding “Your pulse rate is ____bpm, with normal rhythm meaning there is an even tempo with equal intervals between pulsations” Regularly irregular pulse: the pattern of missed beats or variation is predictable (i.e., 3 regular beats then one missed beat called a Pause, which is associated with premature contractions) Sinus arrhythmia involves an irregular pulse rhythm in which the pulse rate varies with the respiratory cycle: the heart rate increases at inspiration and decreases back to normal upon expiration (common in children, adolescents, and young adults) Irregularly irregular pulse: there is no pattern to the irregularity (a.k.a. chaotic rhythm) Irregularly irregular pulses rhythm is highly specific to atrial fibrillation Bradycardia is a heart rate less than 50 bpm and tachycardia is a heart rate greater than 100 bpm In patients with HR > 100 bpm, the positive likelihood ratios predicting mortality in patients with pneumonia is 2.1 and 3.0 in patients with myocardial infarction, while the absence of tachycardia decreases the probability of hospital mortality in patients with trauma and septic shock Pulse deficit: a difference of 2 bpm or more between radial pulse rate and the apical pulse rate (the apical rate always being greater) This has traditionally been associated with atrial fibrillation, but is commonly found with al extrasystoles or fast HR and by itself has little diagnostic significance Respiratory Rate Stand to side of patient and place one hand on patient’s shoulder Observe rate, rhythm, depth, and effort of breathing Count to 15 seconds and multiply by 4 Tachypnea: an increase in respiratory rate, occurring with CNS stimulation and as compensation for respiration problems Occurs with exertion, fear, cardiac insufficiency, pain, pulmonary embolism, acute respiratory distress from infections, pleurisy anemia, and hyperthyroidism Bradypnea: decreased respiratory rate Occurs with hypothyroidism, respiratory failure, medication and drug use, or brain injuries Kussmaul Breathing (Hyperpnea): respirations are deep, sighting respiratory pattern Occurs due to increased tidal volume with or without an increased respiratory rate, and is a form of hyperventilation that can be seen with any disorder causing significant acidosis such as uncontrolled diabetes, and toxic ingestion (i.e., alcohol) Cheyne-Stokes Breathing: a pattern of crescendo-decrescendo respirations followed by period of apnea Occurs in patients with HF, usually while asleep Chest Auscultation – Posterior and Anterior Have patient lie supine for anterior exam and in a seated position for posterior exam Use ladder pattern to compare symmetrical lung fields bilaterally Start auscultating at the clavicles, anteriorly, and the apex of the scapula, posteriorly, to cover apices of lungs Auscultate laterally on posterior and mid-axillary lines, to ensure examination of lower lobes and right middle lobe Before the Exam: “Before I begin with the anterior/posterior lung auscultations, I am going to ask that every time you feel my stethoscope touch your skin that you take a deep breath in through your nose and out through your mouth” After the Exam: “I was able to hear normal, vesicular, breath sounds of low pitch, soft intensity, heard over the lung fields bilaterally, and the inspiratory vesicular sounds were clearly longer than expiratory sounds” These lung sounds are called adventitious sounds These include… Wheezing High-pitched Continuous Musical The sound has a shrill/hissing quality Caused by narrowed airways as in COPD or Asthma "Like dashes in time" Expiratory Wheezing - EMTprep.com Rhonchi Low-pitched Continuous Musical This sound has a snoring quality Caused by secretion in airways Clears with coughing in chronic bronchitis "Like dashes in time" Rhonchi Lung Sounds - EMTprep.com Crackles (Rales) Discontinuous Short Non-Musical Intermittent Late Inspiratory Crackles - congestive heart failure, interstitial lung disease Early Inspiratory Crackles - chronic bronchitis Mid-Inspiratory and Expiratory Crackles - bronchiectasis "Like dotes in time" Fine Crackles: high-pitched and soft; duration is 5 to 10 milliseconds Coarse Crackles: low-pitched and loud; duration is 20 to 30 milliseconds Listen here: https://www.easyauscultation.com/crackles-lung-sounds Stridor An inspiratory wheeze High-pitched Loud intensity Musical Quality Heart loudest over the anterior neck Partial laryngeal and tracheal obstructions are the cause Mainly an inspiratory sound Caused by upper respiratory tract obstruction, and croup can cause inspiratory stridor in children Pleural Friction (Rub) Caused by pleural surfaces rubbing against each other due to inflammation Can resemble cracking sounds Auscultation of Transmitted Voice Sounds Use diaphragm of stethoscope to auscultate lung fields bilaterally Use ladder pattern to compare symmetrical areas, bilaterally Egophony Ask the patient to say "E" every time your stethoscope contacts their skin Use ladder pattern to compare symmetrical lung fields bilaterally The sound should be heard as an "E" on auscultation Bronchophony When you auscultate over the large airways, the spoken words can be heard louder and clearer, compared to the peripheral airways Hearing bronchophony over the lung tissue suggests consolidation (air has been replaced by fluid such as blood or water) as in pneumonia, hemorrhage, or pulmonary edema Ask the patient to say "ninety-nine" every time your stethoscope contacts their skin The spoken words are usually heard Whispered Pectoriloquy (exaggerated bronchophony) Ask the patient to WHISPER "ninety-nine" every time stethoscope contacts their skin The whispered words are usually heard very faintly For Egophony, hearing an “A” instead of an “E” suggests consolidation For Bronchophony, if you hear spoken words louder and clearer in an area of lung tissue, compared to rest of lung fields, suggests consolidation For Bronchophony, if the above result is present over an area that is NOT one of the main bronchi, it suggests there is underlying consolidation, like pneumonia For Whispered Pectoriloquy, if you hear spoken words louder and clearer in an area of lung tissue, compared to rest of lung fields, suggests consolidation Chest Percussion – Posterior and Anterior Pleximeter Finger Use distal interphalangeal joint of the non-dominant hand's middle finger as a pleximeter (i.e., to absorb the energy of the strike)   Plexor Finger Use the tip of your dominant hand's middle finger as the plexor (i.e., like a hammer)     Strike   The strike should result from repeated extension and flexion of the wrist, as opposed to the movement of the elbow Avoid percussing on the ribs and scapulae (percussing bones will sound dull) Percuss in the intercostal spaces and in between the scapulae posteriorly Start percussing above the clavicles (anteriorly) and above the scapulae (posteriorly) to cover the apices of the lungs Use the ladder pattern to compare symmetrical lung fields, bilaterally “Thorax is symmetric with good expansion, lungs are resonant, breath sounds vesicular; no rales, wheezes, or rhonchi.” Resonance: Hallow quality Results from percussing over air-filled lungs Can be normal, or heard in left-sided heart failure or chronic bronchitis Dullness: Results from percussing over solid tissue such as masses/tumor, fluid, blood, and organs like heart and liver Pleural effusion, lung tumors, and pneumonia can cause dullness, and atelectasis (percussing over the airless lung fields sounds dull) Hyperresonance: Abnormally long Low-pitched Caused by emphysema, pneumothorax, and COPD Deep Tendon Reflexes Biceps: Elicited by tapping biceps tendon located in the antecubital fossa Patient’s arm should be supinated and slightly flexed, with your thumb placed over the biceps tendon Use the pointed end of your reflex hammer Brachioradialis: Elicited by tapping tendon connecting brachioradialis muscle to radial bone in forearm Patient’s arm should be semi-prone and semi-flexed Use the wide end of your reflex hammer Triceps: Hold patient’s arm (don’t ask them to hold it up themselves) so arm is dangling down, and the back of their elbow is pointed upwards Elicited by tapping the triceps tendon located above the olecranon process Patellar: Elicited by tapping the patellar tendon located just below the patella Patient’s leg should hang freely, with knee slightly flexed Look for contraction of quadriceps muscle and extension of leg Achilles: Elicited by tapping the Achilles tendon located at back of ankle Passively dorsiflex your patient’s foot Observe for plantar flexion as you strike Achilles tendon with your hammer Plantar: Elicited by stroking skin on the sole of foot with end of reflex hammer, starting from lateral heel and moving upward in a curved pattern to ball of foot Look for downward flexion of toes Plantar Reflex: Babinski’s Sign (positive plantar reflex) occurs when big toe dorsiflexes, and other toes fan out This is a sign of an upper motor lesion (a CNS lesion in corticospinal tract) Tests of Cerebral Function Rapid Alternating Movements Ask patient to repeatedly tap palm on thigh, lift hand, flip it over, and tap back of hand down on thigh as rapidly as possible Test bilaterally Observe speed, rhythm, smoothness of movements (note slow or awkward movements) For lower limbs as patient to use ball of each foot to repeatedly tap palms of hands as rapidly as possible Normal = rapid, rhythmic, smooth coordinated movements Finger to Nose Test Use index finger to alternate between touching nose and touching your index finger Move your finger in different positions so patient must switch directions and extend arm fully Test bilaterally Normal = smooth, accurate movements Heel to Shin Test Ask patient to slide heel down their opposite shin and back up Test bilaterally Normal = smooth, accurate movements Rapid Alternating Movements Abnormal = slow, irregular, award movements, can indicate cerebellar disease, basal ganglia disease, or upper motor neuron weakness Finger to Nose Test Abnormal = clumsy, unsteady movements that vary in speed, force, or direction (dysmetria means finger may undershoot/overshoot target, intention tremor means involuntary rhythmic oscillatory muscle contractions during directed and purposeful motor movement) Heel to Shin Test Abnormal = clumsy, unsteady movements that vary in speed, force, or direction (dysmetria means heel may undershoot/overshoot target, heel may oscillate from side to side when running down shin) Gait Examination Observe the patient to assess posture, balance, swinging of their arms and movements of legs Walking across the room, turn around, and come back Walking heel-to-toe in straight line (tandem walking) Walking on toes Walking on heels Romberg Test This is a test of proprioception or position sense Patients stands unsupported with feet TOGETHER and eyes OPEN for 30-60 seconds, then with eyes close for 30-60 seconds The examiner should stand close to patient with outstretched arms in front and behind the patient just in case the patient may lose balance and fall Normal = patient maintains upright posture with minimal swaying Abnormal = a positive Romberg sign (patient loses balance when else are close), may indicate sensory ataxia Can arise from conditions including those affecting the dorsal column such as tabes dorsalis (due to neurosyphilis) and vitamin B12 deficiency Pronator Drift Test Can be performed standing following Romberg Test Ask patient to stand for 20-30 seconds with feet shoulder-width apart, arms outstretched straight forward with palms facing up (supinated), and eyes closed Normal = patient can maintain position of arms (remains supinated in horizontal plane) Abnormal = pronator drift (forearm pronates with or without downward drifting of arm) may indicate a motor neuron lesion or corticospinal tract) Pupillary Responses Direct/Consensual Response: Dim lights to room Have the patient create a divide with their hand over the bridge of their nose between their eyes Ask patient to look in to distance and shine a light at an oblique angle into each pupil in turn Direct response is elicited when the pupil constricts in response to direct illumination Consensual response is elicited when the opposite pupil constricts Test both pupils for direct and consensual responses Accommodation Test: Dim lights to room Hold finger/penlight about 10 cm from patient and ask them to look alternately at your finger/penlight into the distance You should see pupils constrict when looking at nearby object, pupils dilate when looking into distance “Pupils are equal, round, and reactive to light and accommodation” Extraocular Movements Movements are produced by the CN III (oculomotor nerve), CN IV (trochlear), and CN VI (abducens nerve) … H-Test: Ask patient to follow the tip of pen light in an “H” pattern Repeat the test two times, observing each eye individually Make sure you go far enough laterally so that the white of the patient’s eye disappears H-Test: Dysconjugate gaze Nystagmus Lid lag Ophthalmoscopic/Fundoscopic Exam Dim lights in room before exam Hold your ophthalmoscope in your left hand and use your left eye to examine your patient's left eye Hold your ophthalmoscope in your right hand and use your right eye to examine the patient's right eye Adjust the focus of your ophthalmoscope Lens should start at 0 diopters Rotate to the red numbers to correct for myopic (-) refractive errors and green numbers to correct for hyperopic (+) refractive errors Ask patient to look into the distance directly past shoulder Hold thumb of your opposite hand across patient's eyebrow and brace the patient's head Start about 15 inches away and approach patient at a 15° angle from patient's line of vision Shine light beam into pupil and look for red reflex (orange glow) Once you find the red reflex, follow it as you slowly move in closer until you can see the retina Comment on… Red reflex Background of retina Optic disc and physiologic cup Arteries and veins Fovea and macula Otoscopic Exam Make sure to use the pencil grip, as it helps stabilize the examiner's hand against the patient's face This allows the otoscope and your hand to follow any unexpected movements by patient Use your left hand to handle the otoscope when examining the patient's left ear, and your right hand to examine the patient's right ear It is important to straighten out patient's ear canal before inserting the spectrum It optimizes visualization of tympanic membrane and helps to minimize patient discomfort as exam is performed In an adult, you can straighten out ear canal by pulling patient's ear up, out, and back with the opposite hand Comment on… External ear canal (ear wax) Tympanic membrane (colour should be pearly pink/grey) Cone of light Bony landmarks Parks flaccida and pars tensa Abdominal Auscultation Listening in all four quadrants is important, especially if abnormalities are found in the first area These sounds are heard using the stethoscope's diaphragm directly on skin of patient's abdomen Normal Bowel Sounds: Described as “clicks and gurgles” or “rumbling” at a frequency of 5-35 sounds per minute (or one sounds every 5-12 seconds) The length of time for you to listen to assess bowel sounds would be a minimum of 2-5 seconds per location USE A WATCH “I heard normal, active bowel sounds in all four quadrants, they were high-pitched and gurgling sounds” Hypoactive Bowel Sounds: Less than 5 sounds per minute Suggestive of constipation Absent Bowel Sounds: Emergent condition Suggestive of bowel obstruction, peritonitis, intestinal ischemia, or paralytic ileus Hyperactive Bowel Sounds: More than 35 sounds per minute Suggestive of diarrhea, gastroenteritis, inflammatory bowel disease, laxative use, gastrointestinal bleeding, or bowel obstruction Abdominal Palpation LOOK AT YOUR PATIENT’S FACE, NOT YOUR HANDS For majority of test, patient is lying supine on table with their head and knees supported to relax the abdominal wall Add pillow under patient's knees, or ask them to bend knees to create same relaxing effect on abdominal muscles (important for DEEP palpation) Patient's arms should be relaxing at sides (NOT folded behind head) Ensure warm stethoscope, warm hands, and encouraging deep breathing and engaging the patient in conversation) Recommended to start the upper right or lower quadrants Expected tender areas are to be palpated LAST - ask patient to point to specific area of tenderness to ensure you understand which area to palpate last and help build patient rapport Superficial or Light Palpation Performed before deep palpation With gradual pressure, depress abdomen to a depth of 1-2 cm and move pads of fingers in circular or wave-like motion to assess area of abdomen Normal = soft or firm consistency without associated pain or tenderness upon light palpation (consistent throughout abdomen) Guarding is voluntary contraction of muscles to avoid pain or discomfort and tends to be generalized over entire abdomen Abdominal Rigidity is involuntary tightening of muscles in response to underlying inflammation (i.e., peritonitis) To differentiate, implement techniques to relax muscles (rigidity will remain despite the use) If patient is ticklish, use a distraction or "sandwich" technique When tenderness is elicited, describe its location (quadrant), depth of palpation required to elicited (superficial vs. deep), and patient's response (mild or severe) You could ask patient to rate severity of pain on scale of 0 to 10, 10 being greatest pain Deep Palpation With gradual pressure, depress abdomen to depth of 4-5 cm using palmar surface of fingers Use on or two hands If using the two-handed technique, the lower hand is used to assess the abdomen and upper hand is used to apply firm and steady pressure Used to assess masses and organomegaly Describe masses in terms of location, size (dimensions), shape, consistency (soft or firm), and associated pain/tenderness Following the Palpation: “Did you feel any pain for tenderness?” *Allow patient to respond* “Okay so you experienced no pain or tenderness, your abdomen was soft to touch, no masses, swelling or rigidity.” Liver Percussion Midclavicular Liver Span: Start around the 3rd intercostal space on the midclavicular line, lightly percuss 2-3x (should be resonant over lungs) Continue percussing inferiorly until you reach dullness, around the 5th intercostal space (liver’s upper border) Start percussing below the umbilicus on midclavicular line in area of tympany Continue to percuss superiorly until you reach dullness (liver’s inferior border) Measure the distance between your points of dullness Normal liver span on midclavicular line is 6-12 cm Midsternal Liver Span: Repeat the process in the midsternal line, starting to percuss at 3rd intercostal space and percussing inferiorly until dullness is heard Your sternum will naturally dampen percussive sounds, but this dampening effect will be enhanced when the liver is under it Continue percussing inferiorly until dullness disappears OR percuss from just above umbilicus and move superiorly until dullness Measure the distance between the upper and lower points of dullness Normal liver span in midsternal line is 4-8 cm Liver Palpation Begin at patient’s right, lower quadrant Press palpating hand just lateral to the rectus abdominus Ask patient to take a deep breath in and as they inspire, try to feel liver’s edge move inferiorly into your fingers Repeat this as you move your palpating hand superiorly at 1-2 cm increments until lower border of liver is felt Increased tenderness upon touch can suggest inflammation (i.e., hepatitis) or congestion (i.e., congestive heart disease) Edge of a deceased liver can feel firm, irregular, or rounded/blunted Cirrhosis is usually associated with increased firmness, while (rock) hardness and umbilicated nodules along the edge are suggestive of malignancy A palpable mass on the inferior liver edge may be an obstructed, distended gallbladder Fluid Wave Ask patient to make a border with the medial edges of their hands vertically down the midline of abdomen to block transmission of wave through subcutaneous fat Then, you tap or flick the flank while using the other hand to feel for an impulse or thrill Fluid Wave (18:26 to 19:49): Clinical Examination of Cirrhotic Liver Disease – Final Year MBBS Practical Case Assesses for ascites (free-floating fluid in the abdomen) This can detect underlying conditions such as heart failure, liver disease, nephrotic syndrome, or malignancy Shifting Dullness Percuss abdomen starting at center or most protuberant part of abdomen, moving laterally toward flank listening for transition from tympany to dullness Mark location of dullness or keep your fingers there, then ask patient to roll onto side so the dull area is not most superior aspect of abdomen Repeat percussion in that location, and remember to wait approximately 15 seconds for fluid to shift Shifting Dullness (20:52 to 24:02) - Clinical Examination of Cirrhotic Liver Disease - Final Year MBBS Practical Case If ascites is present, the area first assessed dull should become tympanic (air rises to top) and the dullness shifts to dependent side (central area of abdomen which previously was tympanic) This can detect underlying conditions such as heart failure, liver disease, nephrotic syndrome, or malignancy McBurney’s Point Locate by drawing a straight line between the umbilicus and the anterior superior iliac spine (ASIS) Divide the line into thirds McBurney’s point is the meeting place of the upper 2 thirds and lower 1 third How to find McBurney's Point Most important for diagnosing appendicitis It is the point of the abdomen at which tenderness is maximal in cases of appendicitis or inflammation of the ileocecal area (i.e., Crohn’s disease, bacterial infection) Thyroid Inspection (Visual) Ask patient to extend neck slightly Using penlight, shine tangential lighting on thyroid from angle of patient’s chin Visualize the thyroid cartilage and cricoid cartilage (thyroid gland is located inferiorly to cricoid cartilage) Visualize shadow of lower border of thyroid gland Ask patient to swallow Visualize the thyroid gland rising and then returning to resting position when patient swallows, alongside thyroid cartilage, and cricoid cartilage Note the glands symmetry and contour Note any enlargement of thyroid gland or goitre if present “The thyroid gland looks normal and symmetrical bilaterally, it is not enlarged and moves symmetrically upwards with swallowing” In case of enlarged thyroid, note the location (unilateral or bilateral) and the size An enlarged thyroid will move upward with swallowing and goes back to resting position afterwards If mass doesn’t move with swallowing, it is likely not an enlarged thyroid gland Thyroid Palpation Anterior Approach: The Right Lobe Ask patient to flex neck slightly forward and tilt their head to right slightly (10-15º) to help relax the SCM Place pads of your left 2nd, 3rd. and 4th digits on patient’s right thyroid lobe Place pads of your right 2nd, 3rd, and 4th digits on patient’s left thyroid lobe Ask patient to swallow Palpate the thyroid isthmus, not if rising as patient swallows With fingers of your RIGHT hand, push trachea towards side you are palpating (the patient’s right side) Make circular motions with palpating fingers Ensure to palpate the thyroid lobe between trachea and SCM Note the shape, texture, consistency, and gland size, as well as any enlargement or nodules The Left Lobe Ask patient to flex neck slightly forward and tilt their head to right slightly (10-15º) to help relax the SCM Place pads of your right 2nd, 3rd. and 4th digits on patient’s left thyroid lobe Place pads of your left 2nd, 3rd, and 4th digits on patient’s right thyroid lobe Ask patient to swallow Palpate the thyroid isthmus, not if rising as patient swallows With fingers of your LEFT hand, push trachea towards side you are palpating (the patient’s left side) Make circular motions with palpating fingers Ensure to palpate the thyroid lobe between trachea and SCM Note the shape, texture, consistency, and gland size, as well as any enlargement or nodules https://youtu.be/R2WY0t3t11M?si=X3LvOBiEA9_wOzTt Cervical Lymph Nodes Use the pads of your index and middle fingers of both hands and start palpating the following groups bilaterally… Preauricular – anterior to ears Posterior Auricular – posterior to ears, over mastoid process Occipital – at base of skull, on occipital lobe Tonsillar – at the angle of mandible over the tonsils Submandibular – midway between tip of mandible and angle of mandible Submental – tip of mandible on midline Superficial Cervical – over SCM (palpate superficially) Posterior Cervical – posterior to SCM and anterior to trapezius Deep Cervical – alongside and in between the heads of the SCM Ask patient to flex their head slightly forward and to the side that you are palpating to relax the SCM muscles, and place your finger on either side of SCM and deeply palpate Supraclavicular – superior to clavicles (palpate deeply), asking patients to shrug shoulders to give you easier access Infraclavicular – along interior border of clavicles Stanford Medicine 25 Lymph Node Exam (Part 1) Make sure to note the following if a lymph node is palpable… Location – anatomical landmarks, include side of body Size – verbalize and chart diameter Shape – oval, round… Mobility – mobile or fixed Consistency – soft/hard Pain/Tenderness – ask patient to report if any Delimitation – discrete or matted Swelling of a lymph node is defined as lymphadenopathy Causes can include any type of infection such as bacterial, viral, or fungal A small, mobile, soft, non-tender and discrete lymph node can be a normal finding also known as Shotty Nodes A hard and fixed lymph node is a red flag Diffused lymphadenopathy can possibly suggest an HIV infection Spleen Percussion Castell's Sign (Splenic Percussion Sign) Note: because of its accuracy and reliability, this technique should be your focus for practice and examination purposes Find the lowest intercostal space on the left anterior axillary line.  Start percussing continuously. The normal percussion sound in this area is tympanitic.  As you percuss the same point, ask the patient to take a deep breath in.  Upon inspiration, the diaphragm moves inferiorly and pushes the spleen inferiorly as well. Hence, it might push the spleen down under your percussing finger if it is enlarged.  If the spleen is not enlarged, the percussion remains tympanitic during inspiration.  Negative Sign - Can reveal splenomegaly (enlarged spleen) It will enlarge in anterior, inferior, and medial directions When using Castell’s Sign… Positive Sign - Change of tympany to dullness when the patient takes a deep breath suggests splenomegaly and is a positive Castelle's sign.  Some of the causes of Splenomegaly… Hematologic malignancies HIV infection  Mononucleosis  Portal hypertension  Splenic hematoma Splenic infarct  Spleen Palpation The patient is in the supine position.  The examiner stands on the patient's right side.  Reach over the patient and support the left lower rib cage with your left hand. Start palpating for the spleen way below the left costal margin with your right hand.  Keep your hand stationary but apply some pressure.  Ask the patient to take a deep breath. Upon inspiration, the diaphragm moves inferiorly and hence, pushes the abdominal organs inferiorly as well. This would allow the spleen to move towards your palpating hand.  As the patient exhales, move your hand towards the left costal margin and ask them to take another deep breath and repeat the previous step. Keep your palpating hand in the next location, apply some pressure and wait for the spleen to hit your fingertips as the patient takes another deep breath in. Repeat these steps until your palpating hand palpates under the left costal margin.  If you can't palpate the spleen, you can ask the patient to turn to their right side. In this case, gravity will help the spleen to move to a position that makes palpation easier.  If you start too high to palpate the spleen, you might miss the edge of an enlarged spleen.  Examination of the Spleen - Clinical Examination   Palpation Spleen   "  Some of the causes of Splenomegaly… Hematologic malignancies HIV infection  Mononucleosis  Portal hypertension  Splenic hematoma Splenic infarct