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) (5^th midclavicular)
• Pulsations at auscultation points

Palpation:

• Apex beat (PMI)
  • LADS: location (5^th 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, 6^th 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)