PHYSICAL LAITH INTRO.pdf

‫بالبداية بدي نعرف انه كل سستم بنقسم لقسمين اول جزء بعض جزئيات الجينيرال التي تخصه و‬  Chest examination (inspection, palpation, percussion, auscultation) ‫الجزء الثاني الفحص الرئيسي للسستم‬ 1. Inspection (from two site)...

‫بالبداية بدي نعرف انه كل سستم بنقسم لقسمين اول جزء بعض جزئيات الجينيرال التي تخصه و‬  Chest examination (inspection, palpation, percussion, auscultation) ‫الجزء الثاني الفحص الرئيسي للسستم‬ 1. Inspection (from two site) o from the foot of the bed Respiratory System  Chest symmetry  Chest deformity (pectus excavatum, pectus carinatum,  HELP  hyperinflation (barrel chest ))  Respiration type (normal breathing in Male:abdomino- thoracic breathing/ in F: Thoraco-abdominal ) o from the right side of the patient  Skin lesion (nevi, hyperpigmentation,hypopegmentation)  Scar  Dilated vein → indicate SVC obstruction  the patient looks well or ill  Visible pulsation  vital signs (fever,BP,HR,RR)  Hair distribution  any respiratory distress signs  inspect the axilla  Nasal flaring 2. Palpation  Grunting o superficial palpation  Tachypnea  superficial mass, tenderness, emphysema  Cyanosis Chest retraction  Elevated clavicle by sternocleidomastoid muscle o Trachea  tracheal deviation  General examination  Away from the side of lesion:  Hands (CC-TT-RR,HR) pneumothorax, plural effusion, o Peripheral Cyanosis hemothorax o Clubbing  Toward the side of the lesion: upper o Tar staining lobe consolidation, fibrosis and o Tremor: (fine tremor: due to b agonist in asthma patient) / puemonectomy (Flapping tremor→ due to CO2 retention)  Cricosternal distance o RR  If the cricosternal distance less o HR than 3 fingers  hyperinflation  Eyes due to asthma, COPD o Ptosis o Myosis o Heart o conjunctival pallor  palpable apex beat: (position : left fifth intercostal  Neck space mid clavicular line) o JVP: If distended  tension pneumothorax & massive PE  Ankle swelling ( could be pulmonary HTN) 1  o Chest expansion https://www.youtube.com/watch?v=7yDQzSb4Xp8 o breathing sound ‫المقارنة مهمة و ما بخلى الراوند منها‬  put both hands below the nipple and wrap the loos skin bronchial Vesicular , then ask the patient to take a deep harsh fine inspiration and look for your thumb Periphery Trachea or on main bronchus movement ,if one of your thumb move less Inspiration=expiration Inspiration>expiration than the other this suggests ↓expansion  ↓ in chest expansion in case of : Gap between inspiration and No gap (consolidation, fibrosis ) expiration o tactile vocal fremitus : (111 ‫ او‬99 ‫)أربعة و أربعين او‬ o Add sounds https://www.youtube.com/watch?v=2NvBk61ngDY https://www.youtube.com/watch?v=djyRrUrIuw0 a. wheeze  Decrease when  High-pitched musical sounds due to small airway  Pneumothorax narrawing ( COPD +asthma)  Hemothorax  during expiration  plural effusion b. stridor: obstruction in upper airway  collapsing lung with obstructed major bronchi c. Crackles  Increase when  represent   Consolidation  sudden opening of small airways  Fibrosis  Secretions in the airways  lung mass  Lung fibrosis.  lobar collapse  Divided into   Fine crackles pulmonary edema 3. Percussion (compare right and left, from top to bottom ,axilla)  Coarse crackles: bronchopneumonia or https://www.youtube.com/watch?v=GXrBguhXVn8 bronchiectasis o Resonant : normal d. Friction rib (plural rib ) → inflammation o Hyper-resonant : pneumothorax o Dull : the remaining are dullness ( consolidation +collapse o Vocal resonance (111 ‫ او‬99 ‫)أربعة و أربعين او‬ +fibrosis) o Stony dull: pleural effusion & hemothorax 4. Auscultation o First you should comment about  Bilateral air entry (good or reduced)  Bronchial +vesicular sounds  Any add sounds 2   Scar Cardiovascular System  Dilated vein → indicate SVC  HELP  obstruction  Visible pulsation  Hair distribution 2. Palpation  Superficial palpation (no deep palpation in the chest )  superficial mass, superficial tenderness  Apex beat  the patient looks well or ill  Definition: innermost, outermost point at which the  vital signs cardiac impulses can be felt. General examination  location: left fifth ICS at the midclavicular line  Hands: (CC-TT-RR,HR)  Abnormal location of apex beat:  Peripheral Cyanosis o Impalpable apex beat→ overweight or muscular people + barrel chest (hyperinflation) seen in COPD  Clubbing +asthma (If not palpable, roll the patient to the left  Tar staining side)  Tremor : (fine tremor : due to b agonist in asthma patient) /( o Displaced inferiorly and laterally → dilated Flapping tremor→ due to CO2 retention) cardiomyopathy  RR o Palpable on right side → dextrocardia (kartegner  HR syndrome)  Tongue : central cyanosis  character: gentle tapping  Ankle swelling  Heave  Eyes  Definition: forceful pulsation  Palpate with the heel of your right hand firmly over 2 Precordium examination areas 1- Inspection (from two site) o Apex → LVH  from the foot of the bed o Left parasternal area → RVH  Chest symmetry  Thrill  Chest deformity (pectus excavatum , pectus carinatum)  Definition: palpable murmur  Moving with respiration ( normal breathing in male :  Palpate with the palmar aspect of fingers on 3 area abdomino-thoracic breathing / in F: Thoraco-abdominal ) o palpable over the upper right sternal border →  from the right side of the patient aortic stenosis (most common  Skin lesion (nevi , hyperpigmented lesion , hypopegmented thrill) lesion ) o right +left parasternal edge→ VSD o apex →mitral regurgitation 3  3. Auscultation Abdominal examination (inspection, palpation, percussion, auscultation)  Heart sounds: S1+S2+S3+S4  Added sounds 1. Inspection (two sides) o Opening Snap  from the foot of the bed o Ejection click o Umbilicus (normally centrally o Mid-systolic click +inverted) Buttttt in: o Mechanical heart sounds  obese patient →sunken o Pericardial friction Rub  ascites → flat or everted  Murmur o Abdominal respiration (absent in peritonitis) o systolic murmur  normal abdomeothoracic breathing o diastolic murmur o Symmetry & Swelling o continuous murmur  symmetry: symmetrical or not //asymmetrical abdomen suggest #localized mass  swelling Gastrointistinal System  Diffuse abdominal swelling : ascites +intestinal  HELP  obstruction  Localized abdominal swelling : organomegaly +urinary retention  from the right side o #Skin (striae, bruising)  striae  the patient looks well or ill  Asymmetric raised linear streaks  vital signs  Due to: Rapid wt. Gain, Pregnancy, General Examination Cushing Disease.  Hands: (CC-TT-RR,HR)  Bruising, divided into:  cullens sign → hemorrhagic discoloration of the  Peripheral cyanosis umbilical area  clubbing  grey turner sign→ hemorrhagic discoloration of the  tar staining left flank  tremor : (fine tremor : due to b agonist in asthma patient) /(  NOTE: both associated with acute hemorrhagic Flapping tremor→ due to CO2 retention) pancreatitis  RR  HR  Eyes ( sclera for jaundice // conjunctiva for pallor) 4 o #Scars 2. Palpation  Mercedes –benz → liver transplant  Light Superficial Palpation  Kocher →cholecystectomy o Superficial Masses  upper and lower midline→ laproscopy o Superficial Tenderness.  appendectomy scar→ for appendectomy o Guarding and rigidity  pfannenstiel scar→ CS  Deep Palpation o Deep Masses o Deep Tenderness  Palpation For Organomegaly: Liver, Spleen & Kidneys. Masses o Stoma  Palpable mass  Surgically created opening  pathological mass can usually be between skin & hollow distinguished from normal palpable viscus→ To divert feces outside structures by site body, where it’s collected by bag (Ileostomy vs. Colostomy)  Sister Mary Joseph’s nodule→ hard , subcutaneous nodule ,at the umbilicus o Visible dilated veins (due to: indicated to mets cancer  portal hypertension→ caput medusa (produces Tenderness distended veins that drain away from the  site of tenderness is important  Rebound tenderness → when rapidly removing your hand after umbilicus) deep palpation increases the pain (appendicitis )  inf vena cava  Tenderness in the epigastrium suggests peptic ulcer obstruction→ Dilated  right hypochondria → cholecystitis tortuous veins  left iliac fossa→ diverticulitis o hernia (umbilical, periumbilical)  right iliac fossa→ appendicitis or Crohn’s ileitis  incisional hernia at the site of a scar is palpable as a defect in the abdominal wall musculature and becomes more obvious as the patient raises their head off the bed or coughs. 5 Guarding and rigidity 2- A bruit over the liver may be heard in acute alcoholic hepatitis,  Voluntary guarding: is the voluntary contraction of the abdominal hepatocellular cancer and arteriovenous malformation , the muscles when palpation cause pain. most common reason for an audible bruit over the liver,  Involuntary guarding: is the reflex contraction of the abdominal however, is a transmitted heart murmur. muscles when there is inflammation of the parietal peritoneum.  generalized peritonitis→ effect on abdominal breathing and the  Splenomegaly anterior abdominal wall muscles are held rigid (board-like rigidity)  put your hand in the right iliac fossa then ask the patient to deep inspiration and move your hand Palpation for organomegaly (liver /spleen/gallbladder/kidney) obliquely to wars the left  hepatomegaly hypochondria region … the spleen should be enlarge at least 3  place your hand in the right ileac fosaa (the fingers parallel to the rectus sheeth ) then ask the patient to deep inspiration and time to become palpable ascend upward to right costal margin then Feel for the liver  Percuss over the lateral chest wall posterior to the left mid- edge as it descends on inspiration if can possible. axillary line beneath the 9th–11th ribs. → dullness normally  Liver Span : (by Percussion):  causes of the splenomegaly A. percuss on intercostal space until the sound transfer from o myeloproliferative disease resonant to dullness (at right 5 IC –space ) o malaria B. percuss on the right iliac fossa then ascend to transfer the o hematological malignancy sound from tempanic to dull. C. measure the distance (normally 8-12cm) NOTE: Important causes of hepatosplenomegaly include:  lymphoma NOTE: Resonance below the fifth intercostal  myeloproliferative disorders space suggests #hyperinflated lungs or  cirrhosis with portal hypertension occasionally the #interposition of the  amyloidosis, sarcoidosis transverse colon between the liver and the diaphragm (Chilaiditi’s sign)  kidney examination A- Bimanual exam  most common cause of hepatomegaly 1- metastatic CA :→THE LIVER BECOME hard and irregular 2- Right side heart failure → the liver soft and tender 3- cirrhosis → early :enlarge…. later on :shrunken 4- Fatty liver (hepatic steatosis) B-renal angle tenderness  NOTES: 1- pulsatile liver indicates tricuspid regurgitation 6  3. Percussion 4. Auscultation (tympanic normally , and dullness if there are mass or fluid )  With the patient supine, place your stethoscope diaphragm to the right of the umbilicus and do not move it.  percussion all 9 quadrant regions  Listen for up to 2 minutes before concluding  percussion of ascites (accumulation of intraperitoneal fluid) that bowel sounds are absent. - shifting dullness (mild to moderate) +thrill (massive ascites)  Listen above the umbilicus over the aorta for arterial bruits. Shifting dullness  Now listen 2–3 cm above and lateral to the umbilicus for bruits from renal artery stenosis.  after ask the patient to turn on the opposite site →Pause for 10  Listen over the liver for bruits. seconds to allow any ascites to gravitate  causes of ascites mainly : hepatic cirrhosis +portal hypertension Succession splash test :  splash more than 4 hours after the patient has eaten or drunk anything indicates →delayed gastric emptying –pyloric stenosis Bowel sounds  Normal bowel sounds are gurgling and occur every 5-10 sec  peritonitis +paralytic ileus→ absent bowel sound  intestinal obstruction → increased frequency and volume Fluid thrill  atheromatous or aneurysmal aorta→ bruits  (perihepatitis) or (perisplenitis)→ friction rib  place the edge of their hand on the midline of the abdomen →This prevents transmission of the impulse via the skin rather than ###at the end Don’t forget to Mention that You Have to Examine.. through the ascites 1. External Genetalia.  ripple against your left hand,→ If you still feel a ripple against your 2. Hernial orifices. left hand, a fluid thrill is present 3. DRE (PR). 4. Back. 5. LL Edema 7