ThaiUSMLE
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I would like to ask you many points about the physical examination.
First, about full pulmonary examination.
Inspection, palpation , percussion and ascultation
" I need to untie your gown, so I can check your lungs. Is that ok with you?
I will start from the back. Let me take a look at your back.(inspection)
I'm going to press lightly on your back.(palpation) Please, tell me if it hurt.
Please,take a deep breath in and out.(expansion)
Please, say 99. again. Thank you.(tactile fremitus) (Check 6 points, only one at a time, beware scapula)
I gonna tap on your back(percussion) (6 points)
I'm going to listen to your lungs. Please,take deep breaths in and out. (Check 6 points, only one at a time, beware scapula)
OK. I need to check your lungs from the front, so please lower your gown. Thank you."
I will do the same at the front. Is that right?
Do I need to check 6 points from the front? Where are those 6 points?
Please comment on my words that I say to the patient.
About the brief pulmonary exam, such as in depression case or arm pain case.
Do I need to listen both back and front (6 points each)?
About Cardiovascular exam.
Carotid pulse, bruit
Peripheral pulse, Color of nails
JVD
Heart PMI, heave, thrill, ascultation (supine and upright)
Edema
Is that complete?
About abdominal exam.
Inspection- distension, scar, discoloration
Ascultation
percussion
palpation - light, deep , special test ,etc.
If patient have pain at RLQ when I do light palpation. I've already told him that " I know that you are really in pain, but this test is very important. I will do it as quickly and gently as possible" Do I have to do deep palpation at the same point again? How about rebound tenderness? How can I do it correctly?
Thank you for your help.
ThaiUSMLE
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| CSobsessed
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ThaiUSMLE, you sound good. Good job
Just a few points. You ask the patient take a deep breath in and out through his mouth. Because if you do not add it the patient still will breath through his nose. During auscultation be sure that you keep the stethoscope in place untill the patient fully exhale. Only then you move stethoscope to another point. The patient can cough, so you wait patiently untill he finishes coughing. You do tactile fremitus, percussion, auscultation on front in 4 points: right under clavicular level ( L and R) and a little bit lower but above nipples ( L and R).Do not forget that you proceed in level fasion. You look at the nails( cyanosis,clubbing)in pulmonary looking for chronic hypoxia. And if you do full pulmonary-- also auscultate heart(4 points while sitting). If you wanna do brif pulmonary in any other case you just listen to the lungs: 3X2 back; 2x2 front.
Cardiovascular: carotid-- fist auscultation, THEN palpation ( one side at a time). JVD-- do not forget that you have to set up table at approx. 30 degree. Peripheral pulse--besides carotids you do radial, posterior tibial,and dorsalis pedis symmetrically. Also you forgot costochondral tenderness.
Abdominal: if the abdomen is tender by ligh palpation you are PROHIBITED to do deep palpation because you cause unnessary suffering to the patient. What you MUST do in this case is rebound tenderness because you suspect peritonitis. So, you say: " I am going to press on your belly and then let it go quickly. Please, you will tell me does it hurt more when I press in or let it go?" And then you do what you just said. Do not forget that if you are doing a full abdominal exam then a patient probably needs rectal exam and if woman plus pelvic exam. So do not forget to order those two on the first line of your work-up in the patient note.
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| ThaiUSMLE
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Thank you very much.  Csobsessed You are great!!!!
Which specialty you want to match?(If you can tell me.:nod I want to match in IM this year.
I still have some points to clarified about rebound tenderness.
If patient have a pain at RLQ, I have to do rebound tenderness at LUQ. Is that right? (try to stay away from pain)
Thank you for your help.
ThaiUSMLE
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| CSobsessed
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ThaiUSMLE, I am glad that I am able to help a little. It is not me who is Great. Kaplan course was really great. I am a pediatrician so will be applying IM, peds.
You are right about rebound tenderness.Check away from pain. If the whole abdomen involved and patient grab your arm when you are gong to touch, you tell him that it is very important for the diagnosis. Peak any lower quadrant.
the possible things wich could happen: like a patient with diarea tell you that he needs to go to the bathroom immedietly. Of course you first thought is to strangle a patient because you imagine how much time it will steal from you;0) Be sweet instead and say: " OH, sure, take you time, please, I will be here waiting for you." If you were nice-- the patient suddenly says:" Oh, continue doctor, I changed my mind and can hold it for awhile. If you did not allow him to go-- he will be grumpy and very difficult to talk to him. It was not my case on exam. It is just speculations on what can happen. Another thing which can happen with abdominal pain: they beg you to give them a pain killer. Do not say:"Later" because in the end when you already said good-bye and hold a door nob, he says: "Doctor, do you remember, you promised;0)"
So, you have to deal wish such questions right away. You say:" MR. Smith I can see that you are in great pain I wish I could give you medication righg now but it is not safe for at this moment. PLease, bear with a little longe so I could finish exam and rush lab results in order to find out the cause of such pain. Once we know that we will find a way to resolve the pain. The sentence seems long but it pacify a patient for longer and he will not beg you every 3 seconds for a pill.
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| ThaiUSMLE
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Thank you very much again
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