Table of contents
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
- Whispered pectroriloque: ask patient to whisper one-two-three
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)
Comments