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Physical Examination: Systematic and thorough inspection of the patient for physical signs of disease or abnormality.

Proper Adjustment of Patient Attire during the Physical Exam

JoVE 10147

Source: Jaideep S. Talwalkar, MD, and Joseph Donroe, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

In order to optimize the predictive value of the physical examination, the provider must perform maneuvers correctly. The proper use of drapes is an important component of correctly performing physical examination maneuvers. Skin lesions are missed when "inspection" occurs through clothing, crackles are erroneously reported when the lungs are examined through a t-shirt, and subtle findings on the heart exam go undetected when auscultation is performed over clothing. Accordingly, the best practice standards call for examining with one's hands or equipment in direct contact with the patient's skin (i.e., do not examine through a gown, drape, or clothing). In addition to its clinical value, the correct draping technique is important for improving the patient's comfort level during the encounter. Like all other aspects of the physical exam, it takes deliberate thought and practice to find the right balance between draping, which is done to preserve patient modesty, and exposure, which is necessary to optimize access to the parts that need examination. Individual provider styles in the use of gowns and drapes vary consider


 Physical Examinations I

General Approach to the Physical Exam

JoVE 10043

Source: Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

The examination of the body is fundamental to the practice of medicine. Since the Roman Empire, physicians have described the connection between alterations in function of specific parts of the body and specific disease states and have sought to further scientific understanding to improve bedside diagnosis. However, in this modern age of increasing technology within medical diagnostics, it is important to consider the role that physical examination plays today. It is misguided to believe that physical examination holds all the answers, and much has been written about the questionable utility of certain maneuvers previously held in high regard. It is equally misguided to suggest that physical examination plays little role in the modern patient encounter. Physical examination remains a valuable diagnostic tool; there are many diagnoses that can only be made by physical examination. A diagnosis made by labs or imaging is rarely done in the absence of findings detectable at the bedside. As the provider conducts a history and physical, they are actively generating and testing hypotheses to explain the patient's condition. The information one gathers may not replace the need


 Physical Examinations I

Abdominal Exam I: Inspection and Auscultation

JoVE 10088

Source: Alexander Goldfarb, MD, Assistant Professor of Medicine, Beth Israel Deaconess Medical Center, MA

Gastrointestinal disease accounts for millions of office visits and hospital admissions annually. Physical examination of the abdomen is a crucial tool in diagnosing diseases of the gastrointestinal tract; in addition, it can help identify pathological processes in cardiovascular, urinary, and other systems. As physical examination in general, the examination of the abdominal region is important for establishing physician-patient contact, for reaching the preliminary diagnosis and selecting subsequent laboratory and imaging tests, and determining the urgency of care. As with the other parts of a physical examination, visual inspection and auscultation of the abdomen are done in a systematic fashion so that no potential findings are missed. Special attention should be paid to potential problems already identified by the patient's history. Here we assume that the patient has already been identified, and has had history taken, symptoms discussed, and areas of potential concern identified. In this video we will not review the patient's history; instead, we will go directly to the physical examination. Before we get to the examination, let's briefly review s


 Physical Examinations II

Elbow Exam

JoVE 10207

Source: Robert E. Sallis, MD. Kaiser Permanente, Fontana, California, USA

The elbow is a hinged joint that involves the articulation of 3 bones: the humerus, radius, and ulna. It is a much more stable joint than the shoulder, and because of that, the elbow has less range of motion. The elbow and its structures are prone to significant injuries, particularly with repetitive motion. Lateral and medial epicondylitis (also called tennis elbow and golfer's elbow) are two common diagnoses and often occur as a result of occupational activities. When examining the elbow, it is important to remove enough clothing so that the entire shoulder and elbow can be inspected. It is important to compare the injured elbow to the uninvolved side. A systematic evaluation of the elbow includes inspection, palpation, range of motion (ROM) testing, and special tests, including maneuvers to evaluate ligamentous stability and stretch tests to accentuate pain caused by epicondylitis.


 Physical Examinations III

Cranial Nerves Exam I (I-VI)

JoVE 10091

Source:Tracey A. Milligan, MD; Tamara B. Kaplan, MD; Neurology, Brigham and Women's/Massachusetts General Hospital, Boston, Massachusetts, USA

During each section of the neurological testing, the examiner uses the powers of observation to assess the patient. In some cases, cranial nerve dysfunction is readily apparent: a patient might mention a characteristic chief complaint (such as loss of smell or diplopia), or a visually evident physical sign of cranial nerve involvement, such as in facial nerve palsy. However, in many cases a patient's history doesn't directly suggest cranial nerve pathologies, as some of them (such as sixth nerve palsy) may have subtle manifestations and can only be uncovered by a careful neurological exam. Importantly, a variety of pathological conditions that are associated with alterations in mental status (such as some neurodegenerative disorders or brain lesions) can also cause cranial nerve dysfunction; therefore, any abnormal findings during a mental status exam should prompt a careful and complete neurological exam. The cranial nerve examination is applied neuroanatomy. The cranial nerves are symmetrical; therefore, while performing the examination, the examiner should compare each side to the other. A physician should approach the examination in a


 Physical Examinations III

A Novel Method: Super-selective Adrenal Venous Sampling

1Department of Radiology, Nerima Hikarigaoka Hospital, 2Department of Uro-Oncology, Saitama Medical University International Medical Center, 3Endocrinology & Diabetes Center, Yokohama Rosai Hospital, 4Division of Endocrinology and Metabolism, Kanazawa University Graduate School of Medicine, 5Department of Medical Education, School of Medicine, California University of Science and Medicine, 6Department of Pathology, Saitama Medical University International Medical Center, 7Department of Radiology, Yokohama Rosai Hospital

JoVE 55716


 Medicine

Abdominal Exam III: Palpation

JoVE 10089

Source: Alexander Goldfarb, MD, Assistant Professor of Medicine, Beth Israel Deaconess Medical Center, MA

Abdominal palpation, if performed correctly, allows for examination of the large and relatively superficial organs; for a skilled examiner, it allows for assessment of the smaller and deeper structures as well. The amount of information that can be obtained by palpation of the abdominal area also depends on the anatomical characteristics of the patient. For example, obesity might make palpation of internal organs difficult and require that additional maneuvers be performed. Abdominal palpation provides valuable information regarding localization of the problem and its severity, as abdominal palpation identifies the areas of tenderness as well as presence of organomegaly and tumors. The specific focus of palpation is driven by the information collected during history taking and other elements of the abdominal exam. Palpation helps to integrate this information and develop the strategy for subsequent diagnostic steps.


 Physical Examinations II

Abdominal Exam IV: Acute Abdominal Pain Assessment

JoVE 10120

Source: Joseph Donroe, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

Abdominal pain is a frequent presenting concern in both the emergency department and the office setting. Acute abdominal pain is defined as pain lasting less than seven days, while an acute abdomen refers to the abrupt onset of severe abdominal pain with features suggesting a surgically intervenable process. The differential diagnosis of acute abdominal pain is broad; thus, clinicians must have a systematic method of examination guided by a careful history, remembering that pathology outside of the abdomen can also cause abdominal pain, including pulmonary, cardiac, rectal, and genital disorders. Terminology for describing the location of abdominal tenderness includes the right and left upper and lower quadrants, and the epigastric, umbilical, and hypogastric regions (Figures 1, 2). Thorough examination requires an organized approach involving inspection, auscultation, percussion, and palpation, with each maneuver performed purposefully and with a clear mental representation of the anatomy. Rather than palpating randomly across the abdomen, begin palpating remotely from the site of tenderness, moving systematically toward the tender region, and thi


 Physical Examinations II

Palpation

JoVE 10143

Source: Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

The physical examination requires the use of all of the provider's senses to gain information about the patient. The sense of touch is utilized to obtain diagnostic information through palpation.

The specific parts of the examiner's hand used for palpation differ based on the body part being examined. Because of their dense sensory innervation, the finger pads are useful for fine discrimination (e.g., defining the borders of masses, lymph nodes) (Figure 1). The dorsal surface of the hand provides a rough sense of relative temperature (Figure 2). The palmar surfaces of the fingers and hands are most useful for surveying large areas of the body (e.g., abdomen) (Figure 3). Vibration is best appreciated with the ulnar surface of the hands and 5th fingers (e.g., tactile fremitus) (Figure 4). While palpation is fundamental to the diagnostic aspect of the physical exam, it is also important to acknowledge the role that touch plays in communicating caring and comfort during the patient encounter. Patients generally perceive to


 Physical Examinations I

Observation and Inspection

JoVE 10119

Source: Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

Observation and inspection is fundamental to physical examination and begins at the first point of contact with a patient. While observation and inspection are often used interchangeably, observation is a general term that refers to the careful use of one's senses to gain information. Inspection is an act limited to what one can observe visually, and when referring to physical examination, typically refers to findings on the surface of the body, rather than to behaviors. Skilled clinicians utilize all of their senses to assist with gaining an understanding of their patients, relying on vision, touch (percussion and palpation), and hearing (percussion and auscultation) primarily. Smell can also provide important diagnostic information during the patient encounter (e.g., personal hygiene, substance use, or metabolic diseases). Fortunately the sense of taste is largely a historical relic in medicine, though it is interesting to note that diabetes mellitus was diagnosed for many centuries by the sweet taste of the urine. Through experience, clinicians develop an important sixth sense - the gut instinct - that can only be gained through deliberate practice of clinical skills on thousands of pati


 Physical Examinations I

Percussion

JoVE 10136

Source: Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

Simply stated, percussion refers to the striking of one object against another to produce sound. In the early 1700s, an Austrian inn-keeper's son, named Leopold Auenbrugger, discovered that he could take inventory by tapping his father's beer barrels with his fingers. Years later, while practicing medicine in Vienna, he applied this technique to his patients and published the first description of the diagnostic utility of percussion in 1761. His findings faded into obscurity until the prominent French physician Jean-Nicolas Corvisart rediscovered his writings in 1808, during an era in which great attention was focused on diagnostic accuracy at the bedside.1 There are three types of percussion. Auenbrugger and Corvisart relied on direct percussion, in which the plexor (i.e. tapping) finger strikes directly against the patient's body. An indirect method is used more commonly today. In indirect percussion, the plexor finger strikes a pleximeter, which is typically the middle finger of the non-dominant hand placed against the patient's body. As the examiner's finger strikes the pleximeter (or directly against the surface of the patient's body)


 Physical Examinations I

Peripheral Vascular Exam

JoVE 10122

Source: Joseph Donroe, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

The prevalence of peripheral vascular disease (PVD) increases with age and is a significant cause of morbidity in older patients, and peripheral artery disease (PAD) is associated with cardiovascular and cerebrovascular complications. Diabetes, hyperlipidemia, hypertension, and tobacco use are important disease risk factors. When patients become symptomatic, they frequently complain of limb claudication, defined as a cramp-like muscle pain that worsens with activity and improves with rest. Patients with chronic venous insufficiency (CVI) often present with lower extremity swelling, pain, skin changes, and ulceration. While the benefits of screening asymptomatic patients for PVD are unclear, physicians should know the proper exam technique when the diagnosis of PVD is being considered. This video reviews the vascular examination of the upper and lower extremities and abdomen. As always, the examiner should use a systematic method of examination, though in practice, the extent of the exam a physician performs depends on their suspicion of underlying PVD. In a patient who has or is suspected to have risk factors for vascular disease, the vascular exam should be thorough, beginning with inspection, fo


 Physical Examinations I

Lymph Node Exam

JoVE 10061

Source: Richard Glickman-Simon, MD, Assistant Professor, Department of Public Health and Community Medicine, Tufts University School of Medicine, MA

The lymphatic system has two main functions: to return extracellular fluid back to the venous circulation and to expose antigenic substances to the immune system. As the collected fluid passes through lymphatic channels on its way back to the systemic circulation, it encounters multiple nodes consisting of highly concentrated clusters of lymphocytes. Most lymph channels and nodes reside deep within the body and, therefore, are not accessible to physical exam (Figure 1). Only nodes near the surface can be inspected or palpated. Lymph nodes are normally invisible, and smaller nodes are also non-palpable. However, larger nodes (>1 cm) in the neck, axillae, and inguinal areas are often detectable as soft, smooth, movable, non-tender, bean-shaped masses imbedded in subcutaneous tissue. Lymphadenopathy usually indicates an infection or, less commonly, a cancer in the area of lymph drainage. Nodes may become enlarged, fixed, firm, and/or tender depending on the pathology present. For example, a soft, tender lymph node palpable near the angle of the mandible may indicate an infected tonsil, whereas a firm, enlarged, non-tender lymph


 Physical Examinations II

Peripheral Vascular Exam Using a Continuous Wave Doppler

JoVE 10123

Source: Joseph Donroe, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

Peripheral vascular disease (PVD) is a common condition affecting older adults and includes disease of the peripheral arteries and veins. While the history and physical exam offer clues to its diagnosis, Doppler ultrasound has become a routine part of the bedside vascular examination. The video titled "The Peripheral Vascular Exam" gave a detailed review of the physical examination of the peripheral arterial and venous systems. This video specifically reviews the bedside assessment of peripheral arterial disease (PAD) and chronic venous insufficiency using a handheld continuous wave Doppler. The handheld Doppler (HHD) is a simple instrument that utilizes continuous transmission and reception of ultrasound (also referred to as continuous wave Doppler) to detect changes in blood velocity as it courses through a vessel. The Doppler probe contains a transmitting element that emits ultrasound and a receiving element that detects ultrasound waves (Figure 1). The emitted ultrasound is reflected off of moving blood and back to the probe at a frequency directly related to the velocity of blood flow. The reflected signal is detected and transduced to an audible sound with a frequen


 Physical Examinations I

Operating Procedures of the Electrochemotherapy for Treatment of Tumor in Dogs and Cats

1Clinic for Surgery and Small Animals, Veterinary Faculty, University of Ljubljana, 2Department of Experimental Oncology, Institute of Oncology Ljubljana, 3Faculty of Health Sciences, University of Primorska, 4IPBS (Institut de Pharmacologie et de Biologie Structurale), CNRS, 5IPBS (Institut de Pharmacologie et de Biologie Structurale), Université de Toulouse

JoVE 54760


 Cancer Research

Motor Exam I

JoVE 10052

Source:Tracey A. Milligan, MD; Tamara B. Kaplan, MD; Neurology, Brigham and Women's/Massachusetts General Hospital, Boston, Massachusetts, USA

Abnormalities in the motor function are associated with a wide range of diseases, from movement disorders and myopathies to strokes. The motor assessment starts with observation of the patient. When the patient enters the examination area, the clinician observes the patient's ability to walk unassisted and the speed and coordination while moving. Taking the patient's history provides an additional opportunity to observe for evidence of tremors or other abnormal movements, such as chorea or tardive dyskinesia. Such simple but important observations can yield valuable clues to the diagnosis and help to focus the rest of the examination. The motor assessment continues in a systematic fashion, including inspection for muscle atrophy and abnormal movements, assessment of muscle tone, muscle strength testing, and finally the examination of the muscle reflexes and coordination. The careful systematic testing of the motor system and the integration of all the findings provide insight to the level at which the motor pathway is affected, and also help the clinician to formulate the differential diagnosis and determine the course of the subsequent evaluation and treatment.


 Physical Examinations III

Auscultation

JoVE 10153

Source: Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

Through auscultation, the clinician is able "to eavesdrop on the workings of the body" to gain important diagnostic information.1 Historically, the term "auscultation" was synonymous with "immediate auscultation," in which the examiner's ear was placed directly against the patient's skin. Although this was standard practice for centuries, the method proved inadequate in nineteenth-century France, due to social norms and suboptimal diagnostic yield. This led René Laënnec to invent the first stethoscope in 1816 (Figure 1), a tool that has since become inseparable from auscultation in modern clinical practice, and patients hold it as a symbol of honor and trustworthiness among those who carry them.2 Figure 1. A representative illustration of the first stethoscope invented by René Laënnec. The stethoscope has undergone many technologic advances since Laënnec's initial hollow wooden tube. Practically speaking, the provider mus


 Physical Examinations I

Ankle Exam

JoVE 10191

Source: Robert E. Sallis, MD. Kaiser Permanente, Fontana, California, USA

The ankle and foot provide the foundation for the body and the stability needed for upright posture and ambulation. Because of its weight-bearing function, the ankle joint is a common site of injury among athletes and in the general population. Ankle injuries occur as a result of both acute trauma and repetitive overuse (such as running). The ankle is a fairly simple joint, consisting of the articulation between the distal tibia and talus of the foot, along with the fibula on the lateral side. The ankle is supported by numerous ligaments, most notably the deltoid ligament on the medial side, and laterally by three lateral ligaments: the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). Physical examination of the ankle and the patient history (including the mechanism of the injury and the location of pain) provide diagnostic information that helps the physician to pinpoint specific structures involved in an injury, and are essential for determining the severity of the injury and the subsequent diagnostic steps. When examining the ankle, it is important to closely compare the injured ankle to the uninvolved side. Essential components of the ankle exam i


 Physical Examinations III

Pelvic Exam I: Assessment of the External Genitalia

JoVE 10144

Source:
Alexandra Duncan, GTA, Praxis Clinical, New Haven, CT
Tiffany Cook, GTA, Praxis Clinical, New Haven, CT
Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

The pelvic exam can feel invasive to patients, so it is important to do everything possible to make patients feel comfortable and empowered, rather than vulnerable. Clinicians should be aware of how they are communicating, both verbally and nonverbally, and should give their patients control whenever possible. There are many ways to do this, from how the exam table is positioned to how the patient is engaged throughout the exam. As many as 1 in 5 patients may have experienced sexual trauma; therefore, it is important to avoid triggering those patients, but it's not always possible to know who they are. The exam in this video demonstrates neutral language and techniques that can be employed with all patients to create the best experience possible. It's important to keep the patient covered wherever possible and to minimize extraneous contact. A clinician should be careful to tuck fingers that aren't being used to examine the patient to avoid accidental contact with the clitoris or anus. Before performing the pelvic e


 Physical Examinations II

Abdominal Exam II: Percussion

JoVE 10090

Source: Alexander Goldfarb, MD, Assistant Professor of Medicine, Beth Israel Deaconess Medical Center, MA

Medical percussion is based on the difference in pitch between the sounds elicited by tapping on the body wall. The auditory response to tapping depends on the ease with which the body wall vibrates, and is influenced by underlying organs, strength of the stroke, and the state of the body wall. There are three main medical percussion sounds: resonance (heard over lungs), tympany (heard over the air-filled bowel loops), and dullness (heard over fluid or solid organs). The contrast between dullness vs. tympany or resonance allows for determination of the size and margins of organs and masses, as well as identification of fluid accumulation and areas of consolidation. Percussion remains an intricate part of the physical diagnosis since it was first introduced more than 200 years ago, and is especially useful in examination of the lungs and abdomen. As a part of an abdominal examination, percussion follows visual inspection and auscultation. The examiner should first percuss over each of the nine abdominal regions (epigastric region, right hypochondriac region, left hypochondriac region, umbilical region, right lumbar region, left lumbar region, hypogastric region, right inguinal region, and left


 Physical Examinations II

Thyroid Exam

JoVE 10098

Source: Richard Glickman-Simon, MD, Assistant Professor, Department of Public Health and Community Medicine, Tufts University School of Medicine, MA

The thyroid gland is located in the neck anterior trachea between the cricoid cartilage (above) and the suprasternal notch (below) (Figure 1). It consists of a right and left lobe connected by an isthmus. The isthmus covers the second, third, and fourth tracheal rings, and the lobes curve posteriorly around the sides of the trachea and esophagus. The normal gland, weighing 10 - 25 g, is usually invisible on inspection and often difficult to palpate. A goiter is an enlarged thyroid from any cause. In addition to assessing its size, it is important to palpate the thyroid for its shape, mobility, consistency, and tenderness. A normal thyroid is soft, smooth, symmetrical, and non-tender, and it slides upward slightly when swallowing. Symmetrical enlargement of a soft, smooth thyroid suggests endemic hypothyroidism due to iodine deficiency or one of two prevalent autoimmune disorders: Graves' disease or Hashimoto's thyroiditis. Thyroid nodules are common and usually incidental; however, 10% of thyroid nodules turn out to be malignant. They may be single or multiple, and are most often firm and non-tender. A tender, symmetrical goiter typically indicates thyr


 Physical Examinations II

Lower Back Exam

JoVE 10177

Source: Robert E. Sallis, MD. Kaiser Permanente, Fontana, California, USA

The back is the most common source of pain in the body. Examination of the back can be a challenge due to its numerous structures, including the bones, discs, ligaments, nerves, and muscles-all of which can generate pain. Sometimes, the location of the pain can be suggestive of etiology. The essential components of the lower back exam include inspection and palpation for signs of deformity and inflammation, evaluation of the range of motion (ROM) of the back, testing the strength of the muscles innervated by the nerves exiting in the lumbar-sacral spine, neurological evaluation, and special tests (including the Stork test and Patrick's test).


 Physical Examinations III

Considerations for Rodent Surgery

JoVE 10285

Source: Kay Stewart, RVT, RLATG, CMAR; Valerie A. Schroeder, RVT, RLATG. University of Notre Dame, IN

The Guide for the Care and Use of Laboratory Animals1 dictates that rodent survival surgery be performed aseptically. Aseptic technique utilizes specific practices that minimize the contamination of the surgical site, including patient preparation, surgeon preparation, sterilization of instruments and other supplies, and the use of a clean and controlled environment. Presurgical planning, intraoperative monitoring, and postoperative care are essential for successful recovery of animals from survival surgeries.


 Lab Animal Research

Nose, Sinuses, Oral Cavity and Pharynx Exam

JoVE 10152

Source: Richard Glickman-Simon, MD, Assistant Professor, Department of Public Health and Community Medicine, Tufts University School of Medicine, MA

This video provides an overview of sinus, nose, and throat examinations. The demonstration begins with a brief overview of the anatomy of the region. The upper third of the nose is bony, and the bottom two-thirds are cartilaginous. Air entering the nares passes through the nasal vestibules and into the narrow passageway between the nasal septum medially and the bony turbinates laterally. Beneath each curving turbinate is a groove or meatus. The nasolacrimal duct and most of the air-filled paranasal sinuses drain into the inferior and middle meatuses, respectively. Of the three sets of paranasal sinuses, only the maxillary and frontal can be readily examined. A continuous, highly vascular mucosa lines the entire nasal cavity and sinuses. Figure 1. Anatomy of the Nose. Figure 2. Location of the Major Sinuses. Muscular folds of the lips mark the entrance


 Physical Examinations II

Pericardiocentesis

JoVE 10236

Source: Rachel Liu, BAO, MBBCh, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA

The heart lies within the pericardium, a relatively inelastic fibrous sac. The pericardium has some compliance to stretch when fluid is slowly introduced into the pericardial space. However, rapid accumulation overwhelms pericardial ability to accommodate extra fluid. Once a critical volume is reached, intrapericardial pressure increases dramatically, compressing the right ventricle and eventually impeding the volume that enters the left ventricle. When these chambers cannot fill in diastole, stroke volume and cardiac output are diminished, leading to cardiac tamponade, a life-threatening compression of the cardiac chambers by a pericardial effusion. Unless the pressure is relieved by aspiration of pericardial fluid (pericardiocentesis), cardiac arrest is imminent. Cardiac tamponadeis a critical emergency that can carry high morbidity and mortality. Patients may present in extremis, without much time to make the diagnosis and perform life-saving treatments. Causes of this condition are broken into traumatic and non-traumatic categories, with different treatment algorithms. Stab and gunshot wounds are the primary cause of traumatic tamponade, but it may occur from blunt trauma associated with


 Emergency Medicine and Critical Care

Cardiac Exam III: Abnormal Heart Sounds

JoVE 10135

Source: Suneel Dhand, MD, Attending Physician, Internal Medicine, Beth Israel Deaconess Medical Center

Having a fundamental understanding of normal heart sounds is the first step toward distinguishing the normal from the abnormal. Murmurs are sounds that represent turbulent and abnormal blood flow across a heart valve. They are caused either by stenosis (valve area too narrow) or regurgitation (backflow of blood across the valve) and are commonly heard as a "swishing" sound during auscultation. Murmurs are graded from 1 to 6 in intensity (1 being the softest and 6 the loudest) (Figure 1). The most common cardiac murmurs heard are left-sided murmurs of the aortic and mitral valves. Right-sided murmurs of the pulmonary and tricuspid valves are less common. Murmurs are typically heard loudest at the anatomical area that corresponds with the valvular pathology. Frequently, they also radiate to other areas. Figure 1. The Levine scale used to grade murmur intensity. In addition to the two main heart sounds, S1 and S2, which are normally produced by the closing of heart valves, there are two other abnormal heart sounds, known as S3 and S4. These are also known as


 Physical Examinations I

Continuous Manual Exchange Transfusion for Patients with Sickle Cell Disease: An Efficient Method to Avoid Iron Overload

1Reference Centre of Sickle Cell Disease, Hematology Unit, Robert Debré Hospital, AP-HP, 2School of Pharmacy, Université Paris Descartes, 3Etablissement Français du Sang, Robert Debré Hospital, AP-HP, 4Hematology Unit,, Robert Debré Hospital, AP-HP, Univsité Paris Diderot

JoVE 55172


 Medicine

Manual Muscle Testing: A Method of Measuring Extremity Muscle Strength Applied to Critically Ill Patients

1Outcomes After Critical Illness and Surgery (OACIS) Group, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, 2Critical Care Physical Medicine and Rehabilitation Program, Johns Hopkins Hospital, 3Department of Physical Medicine and Rehabilitation, Johns Hopkins University, 4Department of Rehabilitation Services, University of Maryland Medical System

JoVE 2632


 Medicine

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