Visceral Diagnosis - Clet

Front 1

Palpate Arterial Pulses

Back 1

1. Carotid
2. Subclavian
3. Brachial
4. Radial
5. Ulnar
6. Abdominal Aorta
7. Femoral
8. Popliteal
9. Posterior tibial
10. Dorsal pedal

Assessing for rate, rhythm, amplitude, and contour. Elevated rate indicates tachycardia, Low rate indicates bradycardia

Front 2

Lymph nodes - head and neck

Back 2

1. Occipital
2. Postauricular
3. Preauricular
4. Tonsilar
5. Submandibular
6. Submental
7. Facial
8. Anterior cervical chain
9. Posterior cervical chain
10. Supraclavicular

Assessing for size, consistency, mobility, and condition. Lymph nodes are normally not felt. Infection feels soft, tender, and easily movable. Cancer feels hard, non-tender, and non-movable

Front 3

Lymph nodes - axillary

Back 3

1. Supraclavicular
2. Infraclavicular
3. Epitrochlear
4. Lateral axillary
5. Medial axillary
6. Anterior axillary
7. Posterior axillary

Assessing for size, consistency, mobility, and condition. Lymph nodes are normally not felt. Infection feels soft, tender, and easily movable. Cancer feels hard, non-tender, and non-movable

Front 4

Palpate the thorax - anterior and posterior

Back 4

Palpating for pain, tenderness, masses, and sensations which may indicate sore muscles or tumor

All 8-10 spots, cross arms, raise them

Front 5

Tactile fremitus

Back 5

Palpating with the ball of your hand, have the patient say "99" as you touch each of the 10 areas in the thorax (apices, interscapular, triangle, medial, lateral)


Assessing for symmetry of vibration. Decreased or absent fremitus indicates emphysema or bronchial obstruction. Increased fremitus indicates lung consolidation or compressed lung or tumor

Front 6

Respiratory excursion

Back 6

Take a tissue pull from lateral to medial with both hands at about T8 to T10
Patient takes a deep breath in and out through their mouth

Watching for bilateral symmetrical movement. Lag indicates an underlying lung problem on that side.

Front 7

Evaluate the heart for thrills

Back 7

Check the APETM areas for thrills using the ball of the hand

A thrill is a fine, palpable, rushing vibration resulting from aortic stenosis or mitral stenosis. Indicates a Grade III or better murmur

Front 8

Light and deep palpation of the abdomen

Back 8

3 areas in each quadrant, flexed knees for deep palpation
Palpating for pain, tenderness, masses, and muscle guarding.
If I felt a mass, I would have the pt do a half crunch. A superficial mass will still be palpable or visible (superficial to abdominal muscles). A deep mass will not be palpable or visible because the abdominal muscles will obscure the mass.

Front 9

Standard Maneuver

Back 9

Pull the patient up with left hand under liver area, position right hand with fingers pointing cephalad and have patient take a deep breath and hold. Palpate for livers edge as patient exhales

Nodules, tenderness and irregularity may indicate infection or tumor

Front 10

Middleton's Maneuver

Back 10

Patient place their fist under ribs 11 and 12 on the right side, doc feels with right hand, deep breath and hold, palpate for liver's edge as patient exhales

Nodules, tenderness and irregularity may indicate infection or tumor

Front 11

Hooking Maneuver

Back 11

Hook your fingers under ribs, have patient take a deep breath and hold, palpate for liver's edge, deep breath and hold, palpate for liver's edge as patient exhales

Nodules, tenderness and irregularity may indicate infection or tumor

Front 12

Kidney entrapment

Back 12

Ask the patient to take a deep breath. At the height of inspiration, press the fingers of your two hands together to capture the kidney between the fingers. Ask the patient to breathe out and hold the exhalation while you slowly release your fingers. If you have entrapped the kidney you may feel it slip beneath your fingers.

Pain indicates nephritis or kidney stones

Front 13

Palpate for Spleen

Back 13

Reach across with left hand and pull spleen up, ask patient to take a deep breath and hold as you palpate for spleen's edge with right fingertips (exhale?)

Painful or palpable could indicate splenomegaly or anemia

Front 14

Tracheal Tug

Back 14

Palpate trachea with thumb and index finger just below thyroid isthmus

If a downward tug sensation is felt with a synchronous pulse, this is evidence of an aortic aneurysm.

Front 15

Percuss the thorax - anterior and posterior

Back 15

Percuss the 10 primary areas posterior and anterior (3 at apices, 2 at rest)

Normal sound is resonant. Hyper-resonance indicates air in the lung caused by emphysema or bronchial obstruction.

Dull or flat sound indicates lung consolidation or compressed lung or tumor

Front 16

Identify location and size of:
Liver
Spleen
Gastric Air Bubble

Back 16

Liver - percuss down right midclavicular line until dullness, make horizontal mark, (ICS 5-7), then percuss up the midclavicular line from the umbilicus to the lower border (about costal margin). Should be about 6-12 cm, more indicates fatty liver or jaundice, less indicates cirrhosis or atrophy

Spleen - percuss posterior to midaxillary line, horizontal mark on area of dullness between 6-10 intercostal space. A large spleen indicates splenomegaly or anemia

Gastric Air Bubble - Percuss down midclavicular line for tympanic area. If there is no tympanic sound or if it is enarged, it indicates GERD or dyspepsia

Front 17

Diaphragmatic Excursion

Back 17

Patient takes a deep breath and holds, percuss from inferior angle of scapula down til dulness is heard, make a line, pt breathes all the way out and holds, percuss up from first mark until resonance is heard

Usually 3-5 cm. Excursion limited by emphysema or fractured rib

Front 18

Identify the size and location of heart

Back 18

Percuss and mark moving lateral to medial at the 3rd, 4th, and 5th intercostal spaces (vertical marks), and down the right sternal border until dulness is heard at superior border of liver (6th ICS)

Shifting to the left may indicate left ventricular hypertrophy or pericardial effusion.

Dullness heard superior to the 6th ICS could indicate right atrial enlargement or pericardial effusion

Front 19

Percuss the abdomen

Back 19

3 areas in each quadrant sequentially

Dullness is hear over organs and masses, tympanic sounds indicate air pressure in stomach and intestines

Front 20

Percuss the bladder

Back 20

Percuss from ASIS to ASIS

Dullness indicates distended bladder

Front 21

Bruits of the vessels

Back 21

Use bell, patient holds breath

Temporal arteries
Carotid
Subclavian
Abdominal Aorta
Femoral

low-pitched unexpected sounds that may indicate local obstruction or vigorous blood flow

Front 22

Venous hum

Back 22

use bell, patient holds breath

Base of neck (head to one side, head tilted up)
Epigastric area

low pitch continuous sound that is louder during diastole and caused by turbulent blood flow in internal jugular veins. Common but not pathological in children, may indicate anemia or pregnancy in adults

Front 23

Auscultate for breath sounds

Back 23

(Diaphragm)
have pt breathe once through the mouth each time you place diaphragm on them
Posterior - 10 primary areas
Anterior - 8 areas (above clavicles, above and below breasts)

Assessing for pitch, intensity, and duration of lung sounds. Normal breath sounds are vesicular, bronchovesicular, and bronchial. Adventitious breath sounds are crackles (emphysema), wheezes (asthma), and rubs

Front 24

Vocal Resonance

Back 24

use diaphragm, Just auscultate at apex
1. Bronchophony - normal voice; "normal to sound muffled, ability to hear words clearly indicates consolidation"
2. Whispered pectoriloquy; "normal to hear words faintly, ability to hear words clearly indicates consolidation"
3. Egophony "eeeeee"; "normal to hear a muffled 'ee', hear "aa" indicates consolidation (pneumonia)

Front 25

Evaluate the heart for pulsations

Back 25

Using fingerpads, check for accentuated, diminished , or absent pulsations that indicate underlying cardiac involvement

APET
M - also check apical impulse for location and amplitude
E - Pulsations S-I indicate right ventricular enlargement. I-S (P-A) indicate abdominal aortic aneurysm

Front 26

Special maneuvers for aortic and mitral murmur

Back 26

Mitral - left lateral recumbent position (bell), deep breath and hold

Aortic - seated, find aortic area, use diaphragm, patient leans forward while exhaling

Murmurs are unusual heart sounds

Front 27

Auscultate for bowel sounds

Back 27

Using diaphragm, auscultate 3 spots in each quadrant for five seconds

Usually heard as clicks and gurgles that occur irregularly and range from 5 to 35 per min.
Hyperactive: Possible diarrhea (36 and higher per minute).
Normoactive: Normal (5 to 35 per minute).
Hypoactive: Constipation (1 to 4 per minute).
Absent: Obstruction w/ possible blockage. Medical emergency (ZERO sounds for 5 min.).

Front 28

Auscultate abdominal arteries

Back 28

check for bruits (bell)
Aorta - 1" up and left
Renals - bilateral 2" up and 2" out
Common iliacs - bilateral, 2" down and 2" out

Bruits are low-pitched unexpected sounds that may indicate local obstruction or vigorous blood flow.

Front 29

Friction rubs

Back 29

Using bell have pt take 3 deep breaths, listen at liver and spleen

Sandpaper rubbing sound indicates inflammation of peritoneal surface of an organ from infection or tumors

Front 30

Psoas sign

Back 30

Superior hand on right iliac crest, inferior hand on thigh, pt raises straight leg against resistance

Increased pain indicates appendicitis

Front 31

Obturator Sign

Back 31

Hip and knee at 90, support at knee, apply resistance at ankle to internal and external hip rotation

Increased pain indicates ruptured appendix or pelvic abscess

Front 32

Murphy's punch

Back 32

Strike kidney from posterior bilaterally (about T12-L3)

Pain indicates nephritis or kidney stones

Front 33

Murphy's sign

Back 33

Pain and reflex apnea during one of the liver edge tests indicates cholecystitis

Front 34

Blumberg's Sign

Back 34

Rapid rebound of fingertips from all 4 quadrants of abdomen.

Pain indicates peritonitis

Front 35

Costochondritis

Back 35

Two hands over rib/cartilage junction

Checking for tenderness or inflammation of the costochondral junction. May also be caused by rib misalignment, intercostal muscle strain, or an anterior vertebra

Front 36

Rovsing's Sign

Back 36

Rebound tenderness test performed in lower left quadrant that is felt in lower right quadrant (McBurney's point) indicates appendicitis

Front 37

Rib fractures

Back 37

One hand over sternum

Radiating pain indicates possible rib fracture

Front 38

Heart auscultation - high pitched sounds

Back 38

Ausculate using the diaphragm with firm pressure. Listening for general cardiac sounds in each location
1. Aortic
2. Pulmonic - S2 is best heard at this location. Listen for accentuated, diminished or splitting of sounds
3. Erb’s point
4. Tricuspid
5. Mitral - S1 is best heard at this location. Listen for accentuated, diminished or splitting of sounds. At the Mitral area use the diaphragm and ascultate for S1 while palpating the carotid pulse to see if they are paired. Have the patient take in a deep breath, exhale, and hold while you assess for paring.
6. Epigastric

Accentuated S1 indicates tachycardia, diminished indicates bradycardia

Front 39

Heart auscultation - low pitched sounds

Back 39

Ausculate using the bell with light pressure. Listening for general cardiac sounds in each location

1. Aortic
2. Pulmonic
3. Erb’s point
4. Tricuspid
5. Mitral
6. Epigastric

Accentuated S1 = tachycardia, diminished = bradycardia

Front 40

Auscultatory Blood Pressure

Back 40

Arm should be at the level of the heart. Inflate the diaphragm 30 mmHg above palpatory systolic

Front 41

Palpatory Systolic Blood Presure

Back 41

Inflate cuff 10 mmHg at a time while monitoring radial pulse. When pulse disappears, increase by 30 mmHg and then come back down until the pulse reappears