Medi ci ne 1: I nstr umentati on and Physi cal Exami nati on Secti on 2A 2015

Dr. Isais Lanzona AY 2012-2013 Lecture 2

Pr ecauti ons to Pr event I nf ecti on

Universal Precautions (UP)

Body Substance Isolation (BSI)
Isolation of all moist and potentially
infectious body substances from all
patients
Gloves primarily means of prevention


Standard Precautions (UP and BSI)
Designed to reduce pathogen transmission
in hospitals for all hospitalized patients
Applies to blood, all body fluids, non-intact
skin, and mucous membranes
Use of hand washing, gloves, mask, face
shield, gown
Standards for equipment, environmental
control and patient placement


Transmission-Based Precautions
Designed for care of specific infected
patients
Applies to pathogens spread by air,
droplet, dry skin, or contaminated surfaces


Why Lear n Basi c Cl i ni cal Ski l l s
70% of diagnoses can be made by
hi stor y al one
90% of diagnoses can be made when PE
i s added
Expensive tests conf i r m what is found
during history and PE

The ski l l s necessar y to per f or m H & PE ar e
the f oundati on of cl i ni cal pr acti ce and
shoul d be consi der ed par t of the basi c
sci ence of medi ci ne.



The Physi cal Exami nati on

!It is a safe rule to have no teaching without a
patient for a text, and the best teaching is taught
by the patient himself." # Sir William Oslet









Components of the Physi cal Exami nati on

The five senses:
Looking
Touching
Hearing
Smelling
Tasting
Instruments
Behavior
Maneuvers
Scales

Recommendations for Student Equipment Purchase
Tape measure
Tuning forks
Penlight
Near vision chart
Stethoscope
Ophthalmoscope
Otoscope
Sphygmomanometer
Centimeter tape measurer
Percussion hammer

Exami nati on Techni que

Inspection
Palpation
Percussion
Auscultation

Classic Paradigms ! Heart, Lungs, Abdomen
Inspection
Percussion
Palpation
Auscultation
Special tests

Classic Paradigms - Extremities
Inspection
Palpation
Range of motion
Vascular
Neurologic
Special tests







Medi ci ne 1: I nstr umentati on and Physi cal Exami nati on Secti on 2A 2015
Dr. Isais Lanzona AY 2012-2013 Lecture 2
The Physi cal Exami nati on: I nspecti on

!Don$t touch the patient # state first what you see;
cultivate your powers of observation." Sir William
Osler

Inspection
Process of observation beginning with first
exposure to patient and continuing
through history and physical examination.
Guidelines:
o Adequate lighting
o Unhurried and careful inspection
o Validation of findings with patient

Enhancing your Powers of Observation
Learning physical examination is all about
becoming a better obser ver
A skilled clinician has enhanced power of
observation and the knowledge to use
these observations in the care of patients.

!The precise and intelligent r ecogni ti on and
appr eci ati on of mi nor di f f er ences is the real
essential factor in all successful medical diagnoses."
# Joseph Bell

The Physical Examination: Inspection
General appearance
State of nutrition
Body habitus
Posture and Gait
Speech


Case 1:

Patient is jittery and keeps making fast
frequent movements
Is there anything striking in her
appearance?
o Bulging of eyes; peculiar stare
o Fast frequent movements #
problem with thyroid





Case 2:


The Physi cal Exami nati on: Pal pati on

Use of hands and fingers to gather
information through touch
Guidelines:
o Keep fingernails short.
o Have warm hands.
o Be gentle in approach.
o Use appropriate hand surface.
o Use correct palpation depth.

Touch

!The most important innovation in medicine to
come to the next 10 years: the power of the
human hand." # Abraham Verghese

Surface Anatomy

Question: What is the important landmark
on the chest? STERNAL ANGLE OF LOUIS!
o From there we can know where
it is located # count the ribs,
etc% it$s where the trachea
bifurcates.
Question: Borders of Heart? What forms
the right heart border?




14 year old adolescent boy
what problem does his stature
suggest?
o Look at his arm span and
fingers
o Patient - Gigantism
Medi ci ne 1: I nstr umentati on and Physi cal Exami nati on Secti on 2A 2015
Dr. Isais Lanzona AY 2012-2013 Lecture 2


Case 12:

Q: Which cardiac chamber activity is being
evaluated? RIGHT VENTRICLE
From this model, you can see that it is
the right atrium that forms the right
border of the heart when you examine the
chest.


Case 3:

What is being examined?
o Left Upper Quadrant: SPLEEN




The Physi cal Exami nati on: Pal pati on

One object striking against another
produces vibrations and sound waves.
Tapping finger causes vibrations by impact
on underlying tissues.
Sound waves arise from vibrations and
produce percussion tones.
Tone is related to density of underlying
tissue.

Percussion # Inventum Novum ex Percussione
Thoracis Humani ut Signo Abtrusos Interni Pectoris
Morbos Detegenti

!I present the reader with a new sign, which I have
discovered for detecting diseases of the chest. This
consists in the percussion of the human thorax,
whereby according to the character of the particular
sounds thence elicited, an opinion is formed of the
internal state of that cavity." Leopold von
Auenbrugger

A new discovery that enables the
physician from the percussion of the
human thorax to detect the diseases
hidden within the chest
Leopold Auenbrugger introduced it as a
cornerstone in physical diagnosis in 1716
Dismissed as a plagiarism of the
Hippocratic succusion splash
Recognized when the work was translated
into French by Jean Nicolas Corvisart

The Physical Examination: Percussion
Relates to the tactile sensation and sound
produced when a sharp blow is struck to
an area being examined.
Provides valuable information about the
structure of the underlying organ or tissue.


Medi ci ne 1: I nstr umentati on and Physi cal Exami nati on Secti on 2A 2015
Dr. Isais Lanzona AY 2012-2013 Lecture 2
Percussion


Percuss the lung fields alternating from
top to bottom and comparing sides.
Percuss over the intercostal space and
note the resonance and the feel of
percussion.
Keep the middle finger firmly over the
chest wall along intercostal space and tap
chest over distal interphalangeal joint with
middle finger of the opposite hand.
The movement of the tapping should come
from the wrist.
Tap 2-3 times in a row.
Do not leave the percussing finger on the
chest, otherwise you will dampen the
sound.





Lungs ! resonant
Stomach (tympanitic)
Liver (dull)
Thigh (flat)

Jean-Nicolas Corvisart (1755-1821)
Popularized percussion
Translated Inventum Novum to French
(1807)
Famous physician of Napoleon Bonaparte
Described the palpatory thrill in mitral
stenosis

!I could have raised myself to the rank of an author
by remodeling the work of Auenbrugger and
publishing a work on percussion. But by that I
would sacrifice the name of Auenbrugger to my own
vanity; that I do not wish to do; it belongs to him,
it is his beautiful and rightful discovery which I was
to bring to life." # Jean-Nicolas Corvisart










Medi ci ne 1: I nstr umentati on and Physi cal Exami nati on Secti on 2A 2015
Dr. Isais Lanzona AY 2012-2013 Lecture 2
The Physi cal Exami nati on: Auscul tati on

Listening to sounds produced by body
Guidelines:
o Perform last in examination
sequence.
o Stethoscope is placed on naked
skin.
o Listen for presence/characteristic
of sound.
o Listen to one sound at a time.
o Take time to identify
characteristics of sound.
o Don"t anticipate next sound.

Laennec at the bedside

!Laennec$s ear opened to man a new world in
medical science." # Rogher, !Les Medicinis Bretons"

Placement of Stethoscope
Diaphragm is tightly applied to the chest
o High-pitched sounds
Bell is tightly applied to the chest
o Low-pitched sounds

Auscultation
Auscultate the heart in five locations in a
systemic fashion, starting at the apex,
moving to the left lower sternal border
(including epigastrium) and extend to base
of the heart.
o PMI
o Epigastrium
o Left sternal border
o Second ICS right (aortic)
o Second ICS (pulmonic)
Do this with the following:
o Diaphragm: which best facilitates
hearing high-pitched sounds
including S1 and S2
o Bell: which best facilitates
hearing low-pitched sounds
including S3 and S4

Classic Auscultatory areas


Cardiac Auscultation


Lung Auscultation

Question: Which sound is longer?
o Expiration ! bronchial breath
sounds
Vesicular expiratory is short















Medi ci ne 1: I nstr umentati on and Physi cal Exami nati on Secti on 2A 2015
Dr. Isais Lanzona AY 2012-2013 Lecture 2
The Stanford 25
An initiative to revive the culture of bedside
medicine
Thyroid Exam
Gait Abnormalities
Examination of the Spleen
Examination of the Liver
Liver Disease, Head to Foot
Ascites & Venous Patterns
Knee Exam
Shoulder Exam
Lymph Node Exam
Deep Tendon Reflexes
Cerebellar Exam
Fundoscopic Exam
Pulmonary Exam
Precordial Movements
Cardiac Second Sounds
Neck Veins & Wave Forms
BP & Pulsus Paradoxus
Ankle Brachial Index
The Hand in Diagnosis
Bedside Ultrasound
Rectal Exam
Pupillary Responses
Involuntary Movements
Internal Capsule Stroke
The Tongue in Diagnosis

1. Thyroid Exam: A good thyroid exam depends above all on
knowledge of anatomy and proper technique.
2. Gait Abnormalities: Abnormal gaits are commonly seen in the
hospital and elsewhere. Many of them should be recognizable on
sight and it would be a shame to subject a person to a CAT or
MRI for lack of recognition. We review a number of abnormal
gaits and their disease associations.
3. Examination of the Spleen: An enlarged spleen can be easily
missed. It is a prime example of how technique matters and
even with the best technique, the spleen is not easily felt.
4. Examination of the Liver: The liver, unlike the spleen is easily
located when enlarged and its surface can be readily felt.
5. Liver Diseases, Head to Foot: Many if not most of the signs
of liver disease are paradoxically to be found outside the
abdomen. The clinician needs to be able to elicit and recognize
these signs and here we review them from head to foot.
6. Ascites & Venous Patterns: The simple act of observing
venous patterns and the direction of venous flow on the
abdomen can help us to differentiate inferior vena cava
obstruction from portal hypertension from portal hypertension.
The techniques for detecting ascites are reviewed here.
7. Knee Exam: The knee is one of the most common causes of
joint pain. A good knee exam helps us to rule out serious
conditions such as a septic or inflammatory joint space and can
also help make an accurate anatomical diagnosis of ligament or
meniscus injury.
8. Shoulder Exam: Careful examination of the shoulder can
provide valuable information and help the physician determine
when image studies may or may not be helpful.
9. Lymph Node Exam: Do you know what a #shotty$ lymph
node is? Do you keep your nails neatly trimmed? Learn this and
other tips from our experts and watch them perform a
meticulous lymph node exam.
10. Deep Tendon Reflexes: Subtle changes in your technique can
elicit an otherwise absent deep tendon reflex. Having a proper
reflex hammer helps. Here we review those subtle techniques to
improve on this import exam skill.
11.Cerebellar Exam: A number of signs and symptoms correlate
with cerebellar disease and the clinician needs to be able to
elicit them from head to foot.
12. Fundoscopic Exam: When it comes to an ophthalmoscopic
exam there's more to it than meets the eye! Here we take a
look at the various ophthalmoscopes available to internists and
review their proper use.
13. Pulmonary Exam: The pulmonary exam is more than simple
auscultation--in fact percussion and inspection often tell you
much more than auscultation. Knowing the normal boundaries of
percussion and the surface anatomy is critical.
14. Precordial Movements: Palpation is a critical part of the
cardiac exam. The size and the character of the PMI (PMI) can
speak volumes and predict the presence of an S3 or 4.
15. Cardiac Second Sounds: The second sounds and their
variations can tell us volumes about everything from pulmonary
or systolic hypertension to bundle-branch block.
16. Neck Veins & Wave Forms: Identifying an elevated jugular
venous pulse will almost always affect your management of a
patient. An understanding of waveforms can help you recognize
everything from canon "a" waves of complete heart block to
"ventricularization" of the "v" wave in tricuspid regurgitation.
17. BP & Pulsus Paradoxus: An accurate and reproducible blood
pressure reading is a basic clinical skill. We review that skill and
discuss how to test for pulsus paradoxus.
18. Ankle Brachial Index: Measuring an ankle brachial index is a
simple skill that can be done at the bedside and give you helpful
information about a patient's peripheral circulation. This
technique is reviewed here.
19. The Hand in Diagnosis: The hands are a window to the body,
and changes in the hands are linked to a plethora of illnesses.
Recognizing these phenotypic expressions of disease is a basic
clinical skill.
20. Bedside Ultrasound: With improvement in technology, the
bedside ultrasound is becoming frequent in use. Here we discuss
the principles and basics of bedside ultrasound.
21. Rectal Exam: A rectal exam is important to help rule out
prostate issues, diagnosing causes of perirectal pain and looking
for distal rectal masses. As the saying goes, "If you don't put
your finger in, you will put your foot in!"
Medi ci ne 1: I nstr umentati on and Physi cal Exami nati on Secti on 2A 2015
Dr. Isais Lanzona AY 2012-2013 Lecture 2
22. Pupillary Responses: The pupillary response requires a
complex integration of nerve fibers. An abnormal pupillary
response can be a harbinger for disease or simply a benign
process. We review the physiology behind this reflex and discuss
situations where it will be abnormal.
23. Involuntary Movements: There are many types of involuntary
movements and the diagnosis rests on observation and
knowledge of the types of involuntary movements and their
causes.
24. Internal Capsule Stroke: A stroke within the internal capsule
leads to a unique number of physical exam findings. We review
these changes and compare them with strokes in other
locations.
25. The Tongue in Diagnosis: Changes in the tongue occur in
many situations. Systemic disease such as amyloidosis or
lymphoma will affect its size and color. Localized infections may
suggest underlying immune disorders. Nutritional deficiencies will
cause abnormalities.


Sel ected Appl i cati ons of Poi nt- of - Car e
Ul tr asonogr aphy, Accor di ng to Medi cal Speci al ty
Speci al ty Ul tr asound Appl i cati ons
Anesthesia Guidance for vascular access, regional
anesthesia, intraoperative monitoring of
fluid status and cardiac function.
Cardiology Echocardiography, intracardiac assessment
Critical Care
Medicine
PG, pulmonary assessment, focused
echocardiography
Dermatology Assessment of skin lesions and tumors
Emergency
Medicine
FAST, focused emergency assessment, PG
Endocrinology
and Endocrine
Surgery
Assessment of thyroid and parathyroid, PG
General
Surgery
Ultrasonography of the breast, PG,
intraoperative assessment
Gynecology Assessment of cervix, uterus & adnexa; PG
Obstetrics &
maternal-fetal
medicine
Assessment of pregnancy, detection of
fetal abnormalities, PG
Neonatology Cranial and pulmonary assessments
Nephrology Vascular access for dialysis
Ophthalmology Corneal and retinal assessment
Orthopedic
Surgery
Musculoskeletal applications
Otolaryngology Assessment of thyroid, parathyroid, and
neck masses; PG
Pediatrics Assessment of bladder, PG
Pulmonary
Medicine
Transthroacic pulmonary assessment,
endobrachial assessment, PG
Radiology &
Interventional
Radiology
Ultrasonography taken to the patient with
interpretation at the bedside, PG
Rheumatology Monitoring of synovitis, PG
Trauma
Surgery
FAST, PG
Urology Renal, Bladder and Prostate assessment;
PG
Vascular
Surgery
Carotid, arterial and venous assessment;
PG
PG = Procedural Guidance