UofT Summaries

    Precordial Exam:

    Interview:

    • Pain,
    • Dyspnea,
    • orthopnea (Poor breathing line flat – how many pillows?)
    • paroxysmal nocturnal dyspnea
    • Edema
    • Palpitations
    • Syncope

    Inspection:

    • Scars
    • Bony abnormalities
    • Redness
    • Heaves
    • Implanted pacemakers
    • Pulsations of PMI (apex beat) (5th midclavicular)
    • Pulsations at auscultation points

    Palpation:

    • Apex beat (PMI)
      • LADS: location (5th intercostals), amplitude (tap), duration (2/3 systole), size (quarter)
    • Thrills
    • Heaves
    • Epigastric pulsations
    • Pacemakers – below clavicle

    Auscultation:

    • S1 and S2 (physiologic splitting of S2 on inspiration?) (distinguish, time with radial pulse – S1-pulseS2) (S1-S2 are soft)
    • S3(early diastole) /S4 (late diastole)
    • For S3 and S4 auscultate apex in LLD position using bell

     

    Resp Exam:

    Interview:

    • Chest Pain
    • Dyspnea
    • Wheezing
    • Cough – hemoptysis
    • Smoking

    Inspection:

    • General changes – masses/scars/lesions/clubbinb
    • Respiratory difficulty
    • Trachea midline?
    • Respiratory effort: sternocleidomastoids, scalene, intercostals indrawing
    • Pectus carinatum/excavatum
    • A-P diameter (barrel chested)
    • Behind: kyphosis/scoliosis/lordosis etc.. spinal abnormalities
    • Peripheral cyanosis, Clubbinb
    • Central cyanosis
    • Resp rate

    Palpation:

    • Trachea –tender? Mobile?
    • Tenderness – ask/palpate
    • Chest expansion – equal, bilateral expansion
    • Tactile fremitus  - boy-oh-boy – increase/decrease in each lobe?

    Percussion

    Flat, dull, resonant, hyperresonant, tympanic

    • Diaphragmatic excursion (norm 5-6cm)

    Auscultation – bronchial/adventicious/transmitted voice

    • Normal: vesicular sounds (soft, low pitched)
    • Abnormal adventitial sounds: crackles, wheezes, rhonchi (continuous, low-pitched snoring)
    • If breath sounds abnormal:
      • Whispered pectroriloque: ask patient to whisper one-two-three
        • Normal muffled, abnormal loud and clear
      • Egophony: say Eeee
        • Normal muffled, abnormal Ayyy

    Peripheral Vascular Exam:

    Inspection

    • Hair loss, shiny skin, ulcers, edema

    Palpation

    • Temperature (warm)
    • Cap Refill (3-4sec)
    • Check for edema pitting/non-pitting
    • Pulses
      • Femoral, Popliteal, post. Tibial, dorsalis pedis
    • Aortic Aneurism

    Auscultation

    • Bruits: over abdomen, femoral, popliteal fossa

    Special Maneuvers

    • Pallor on elevation (mild pallor, no venous insufficiency)
    • Rubor on dependency (color return <10s, veins fill in <15 sec, flushing is arterial insufficiency)

    Abdomen Exam:

    Inspection:

    • Scars, lesions,
    • Discoloratyion/Jaundice
    • Contour of abdomen (flat? Protuberant, distended?)
    • Visible Organs/Masses
    • Dilated veins
    • Peristalsis
    • Ascites
    • Bruising (ecchymoses)
      • Cullen’s sign
      • Grey-Turner sign

    Auscultation

    • Bowel sounds (increased?normal? decr?) (low/high pitched) (5-10s)
    • Listen for 2 mins to conclude no bowel sounds
    • Bruits: aortic, renal, iliac, femoral

    Percussion

    • Percuss four quadrants.
      • Tympany: gas; dull à solid structure, fluid; hyperresonance à obstruction;

    Palpation

    • Ask if there is tenderness? Begin away from the tenderness
    • Paplate four quadrants – note guarding, watch their face
    • Looking for areas of fullness or masses – comment size, location, shape, tenderness, pulsations, mobility
    • Rebound tenderness (Peritoneal inflammation)

     

    Gallbladder

    • Murphy’s sign: hand on inf. Border of liver, ask to inhale ( acute cholecystitis)

     

    Kidney

    • Left hand on the back, right hand on the front, attempt to palpate the kidney.  Usually not palpable

     

    Liver Exam

    Inspection:

    • Petechiae
    • Palmar erythema
    • Terry’s nails
    • Asterixis (hand tremor on dorsiflection)
    •  

     

    • Discoloration/Jaundice (Scleral icterus)
    • Scratch marks (excoriation – pruritis)
    • Spider angiomata
    • Ascites/Edema
    • Dilated veins
    • Bruising (ecchymoses)
    • Caput medusa
    • Fetor hepaticus
    • Liver
      • Jaundice
      • Ascites/Edema
      • Hepatomegaly or contracted liver
      • Caput medusa
      • Petechiae
      • Fetor hepaticus
    • Hands
      • Palmar erythema
      • Clubbing
      • Terry’s nails
      • Thenar wasting
      • asterixis

    Percussion

    • Percuss up to find lower border, down from nipple to find upper border (6-12cm)

    Palpation

    • General technique: put hand behind 11/12 ribs, push down to palpate the liver
    • Ask them to breath in, and feel inf. Border of liver, 3cm below costal margin (soft, sharp, regular, smooth).  Tenderness?

    Auscultation

    • Auscultate
      • Hepatic Bruits (tumour, alcoholic hepatitis)
      • Friction rubs
      • Venous hums

     

    Spleen exam

    Interview:

    • Recent weight loss?
    • Feel tired?
    • Ever been told of a problem with blood?
    • Changes in tendency to bleed or bruise?

    Inspection:

    • Masses
    • Scars
    • Lesions
    • Swelling (splenomegaly)

    Percussion:

    • Traube’s space (anterior axillary, 6th rib, costal margin) – percuss (tympanic)
    • Castell’s method – lowest intercostals space, percuss (tympanic), ask to breathe in (tympanic)
    • Percuss from LRQ and up towards ULQ, then ask to take deep breath, check for dullness( Tympanic to percussion?).  If dull at any time: problem.

     

    Appendicitis

    • Point tenderness – ask to point to pain, points to McBurneys point(halfway btwn umbilicus and ASIS)
    • Cough tenderness – ask to cough, point to pain
    • Palpation
      • Rovsing’s Sign: supine patient, palpate LLQ (pain in RLQ)
      • Psoas sign: lie on left, flex right thigh
      • Obturator sign: flex knee, and internally rotate thigh (obturator internis may pain)
      • Rebound tenderness: hold for 15-30sec, and rebound
      • DRE

    Ascites

    • Fluid wave
    • Shifting dullness

     

    Thyroid Exam

    Inspection

    • Extend neck
    • Masses, scars, swelling, lesions, discoloration, muscle atrophy/hypertrophy
    • Exopthalmos
    • Goiter

    Front and side:

    • Inspect the thyroid below cricoids above sternal notch
    • Swallow water and look for rise (normal contour and symmetry)

    Palpation

    • Flex neck
    • Thyroid, cricoids cartilage
    • Isthmus: over 2-4 tracheal rings
    • Masses btwn trachea and SCM
    • Ask swallow, palpate masses

    Auscultation

    • If thyroid enlarged…Use bell to auscultate bruit

     

    Lymph Node Exam

    Inspection

    • The usual: masses, scars, lesions, erythema, swelling, skin changes, deformity, muscle atrophy/hypertrophy/symmetry, discoloration

    Palpation:

    • Patient neck slightly flexed
    • Occipital, Posterior auricular, pre-auricular, submandibular, submental, superficial servical, deep cervical, posterior cervical, supraclavicular, infraclavicular
    • If found, comment on:
      • Size (<2cm)
      • Shape (regular/irregular)
      • Texture (soft/firm)
      • Mobility (mobile)

    Auscultation

    • Carotid bruits (use bell)
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