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Pleural Effusion: Presence of fluid in the pleural cavity resulting from excessive transudation or exudation from the pleural surfaces. It is a sign of disease and not a diagnosis in itself.
 Science Education: Essentials of Emergency Medicine and Critical Care

Tube Thoracostomy

JoVE Science Education

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

Tube thoracostomy (chest tube placement) is a procedure during which a hollow tube is inserted into the thoracic cavity for drainage of fluid or air. Emergency chest tube insertion is performed for definitive treatment of tension pneumothorax, traumatic hemothorax, large-volume pleural effusions, and empyemas. Irrespective of the cause of air and fluid accumulation in the pleural space, the drainage relieves lung compression and enables lung re-expansion. In pneumothorax, air accumulation in the pleural cavity separates pleural layers, which prevents lung expansion during the respiration. Abnormal fluid accumulation, such as in case of hemothorax or empyema, causes separation of the visceral pleura that adheres to lung tissue from the parietal pleura that forms the lining of the chest cavity. The uncoupling of the pleural layers leads to disconnection of chest wall movement from the lung movement, causing respiratory distress. In addition, excessive pressure from overwhelming amounts of air or fluid in the pleura may push the mediastinum away from the central chest, causing inability of blood to return to the heart. In the trauma setting, a chest tube may

 Science Education: Essentials of Physical Examinations I

Respiratory Exam II: Percussion and Auscultation

JoVE Science Education

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

Learning the proper technique for percussion and auscultation of the respiratory system is vital and comes with practice on real patients. Percussion is a useful skill that is often skipped during everyday clinical practice, but if performed correctly, it can help the physician to identify underlying lung pathology. Auscultation can provide an almost immediate diagnosis for a number of acute pulmonary conditions, including chronic obstructive pulmonary disease (COPD), asthma, pneumonia, and pneumothorax. The areas for auscultating the lungs correspond to the lung zones. Each lung lobe can be pictured underneath the chest wall during percussion and auscultation (Figure 1). The right lung has three lobes: the superior, middle, and inferior lobes. The left lung has two lobes: the superior and inferior lobes. The superior lobe of the left lung also has a separate projection known as the lingual. Figure 1. Anatomy of lungs with respect to the chest wall. An approximate projection of lungs and their fissures and lobes

 Science Education: Essentials of Physical Examinations I

Percussion

JoVE Science Education

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)

 Science Education: Essentials of Physical Examinations I

Respiratory Exam I: Inspection and Palpation

JoVE Science Education

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

Disorders of the respiratory system with a chief complaint of shortness of breath are among the most common reasons for both outpatient and inpatient evaluation. The most obvious visible clue to a respiratory problem will be whether the patient is displaying any signs of respiratory distress, such as fast respiratory rate and/or cyanosis. In a clinical situation, this will always require emergent attention and oxygen therapy. Unlike pathology in other body systems, many pulmonary disorders, including chronic obstructive pulmonary disease (COPD), asthma, and pneumonia, can be diagnosed by careful clinical examination alone. This starts with a comprehensive inspection and palpation. Keep in mind that in non-emergency situations the patient's complete history will have been taken already, gaining important insight into exposure histories (e.g., smoking), which could give rise to specific lung diseases. This history can then confirm physical findings as the examination is performed.

 Science Education: Essentials of Physical Examinations II

Abdominal Exam II: Percussion

JoVE Science Education

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

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 Science Education: Essentials of Physical Examinations III

Knee Exam

JoVE Science Education

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

The knee is a hinged joint that connects the femur with the tibia. It is the largest joint in the body, and due to its location in the middle of the lower leg, it is subjected to a variety of traumatic and degenerative forces. Examination of the knee can be quite complex, owing to the fact it is an inherently unstable joint held together by various ligaments and supported by menisci, which act as shock absorbers and increase the contact area of the joint. In addition, the patella lies in front of the knee, acting as a fulcrum to allow the forceful extension of the knee needed for running and kicking. As the largest sesamoid bone in the body, the knee is a common source of pain related to trauma or overuse. When examining the knee, it is important to remove enough clothing so that the entire thigh, knee, and lower leg are exposed. The exam begins with inspection and palpation of key anatomic landmarks, followed by an assessment of the patient's range of motion (ROM). The knee exam continues with tests for ligament or meniscus injury and special testing for patellofemoral dysfunction and dislocation of the patella. The opposite knee should be used as the standard to evaluate the injured knee, provided it has not been previousl

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 JoVE Engineering

Making Record-efficiency SnS Solar Cells by Thermal Evaporation and Atomic Layer Deposition

1Department of Mechanical Engineering, Massachusetts Institute of Technology, 2Laboratory for Manufacturing and Productivity, Massachusetts Institute of Technology, 3School of Engineering and Applied Sciences, Harvard University, 4Department of Materials Science and Engineering, Massachusetts Institute of Technology, 5Department of Chemistry & Chemical Biology, Harvard University


JoVE 52705

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 Science Education: Essentials of Emergency Medicine and Critical Care

Needle Thoracostomy

JoVE Science Education

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

A tension pneumothorax is a life-threatening situation in which excess air is introduced into the pleural space surrounding the lung, either through trauma to the chest cavity or as a spontaneous leak of air from the lung itself. Air trapped within the pleural space causes separation of the lung from the chest wall, disrupting normal breathing mechanisms. Pneumothorax may be small without conversion to tension, but when there is a significant and expanding amount of air trapped in the pleural cavity, the increasing pressure from this abnormal air causes the lung to shrink and collapse, leading to respiratory distress. This pressure also pushes the mediastinum (including the heart and great vessels) away from its central position, causing inability of blood to return to the heart and diminishing the cardiac output. Tension pneumothoraces cause chest pain, extreme shortness of breath, respiratory failure, hypoxia, tachycardia, and hypotension. They need to be relieved emergently when a patient is in extremis. Tension pneumothoraces are definitively managed by procedures that allow removal of trapped air, such as insertion of a chest tube. However, materials for chest tube placement are typically

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 JoVE Cancer Research

Long-term High-Resolution Intravital Microscopy in the Lung with a Vacuum Stabilized Imaging Window

1Department of Developmental and Molecular Biology, Albert Einstein College of Medicine, 2Department of Obstetrics/Gynecology and Woman’s Health, Albert Einstein College of Medicine, 3Department of Anatomy & Structural Biology, Albert Einstein College of Medicine, 4Gruss-Lipper Biophotonics Center Integrated Imaging Program, Albert Einstein College of Medicine, 5Medical Research Council Centre for Reproductive Health, Queen’s Medical Research Institute, University of Edinburgh


JoVE 54603

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 JoVE Medicine

Surgical Fixation of Sternal Fractures: Preoperative Planning and a Safe Surgical Technique Using Locked Titanium Plates and Depth Limited Drilling

1Orthopedic and Trauma Surgery, University Hospital Erlangen, 2Pediatric Surgery, University Hospital Erlangen, 3Orthopedic and Trauma Surgery, St.-Theresien Hospital, 4Institute of Anatomy I, University Erlangen-Nuremberg


JoVE 52124

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 JoVE Medicine

Automated Measurement of Microcirculatory Blood Flow Velocity in Pulmonary Metastases of Rats

1Division of Plastic, Maxillofacial, and Oral Surgery, Duke University Medical Center, 2Department of Radiation Oncology, Duke University Medical Center, 3Department of Cardiology, University of Colorado Denver, 4Department of Physical Chemistry, University of Mainz


JoVE 51630

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 JoVE Bioengineering

Optical Frequency Domain Imaging of Ex vivo Pulmonary Resection Specimens: Obtaining One to One Image to Histopathology Correlation

1Department of Pathology, Harvard Medical School, 2Massachusetts General Hospital, 3Wellman Center for Photomedicine, Harvard Medical School, 4Pulmonary and Critical Care Unit, Massachusetts General Hospital, 5Pulmonary and Critical Care Unit, Harvard Medical School


JoVE 3855

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 JoVE In-Press

Ultrasound-guided Intracardiac Injection of Human Mesenchymal Stem Cells to Increase Homing to the Intestine for Use in Murine Models of Experimental Inflammatory Bowel Diseases

1Division of Gastroenterology and Liver Disease, University Hospitals, Digestive Health Research Institute, Case Western Reserve University, 2Case Cardiovascular Research Institute, School of Medicine, Case Western Reserve University, 3Department of Medicine, Harrington Discovery Institute, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, 4Department of Radiology, University Hospitals Case Medical Center, 5Department of Biology, Skeletal Research Center, Case Western Reserve University

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JoVE 55367

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 JoVE Neuroscience

A Behavioral Assay for Mechanosensation of MARCM-based Clones in Drosophila melanogaster

1Department of Biology, College of the Holy Cross, 2School of Medicine, Georgetown University, 3Department of Biochemistry, Giesel School of Medicine, Dartmouth College, 4School of Medicine, Tufts University, 5Transgenomic Inc., 6Department of Molecular, Cell and Cancer Biology, UMass Medical School


JoVE 53537

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 Science Education: Essentials of Physical Examinations II

Ear Exam

JoVE Science Education

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

This video describes the examination of the ear, beginning with a review of its surface and interior anatomy (Figure 1). The cartilaginous auricle consists of the helix, antihelix, earlobe, and tragus. The mastoid process is positioned just behind the earlobe. The slightly curving auditory canal ends at the tympanic membrane, which transmits sound waves collected by the external ear to the air-filled middle ear. The Eustachian tube connects to the middle ear with the nasopharynx. Vibrations of the tympanic membrane transmit to the three connected ossicles of the middle ear (the malleus, incus, and stapes). The vibrations are transformed into electrical signals in the inner ear, and then carried to the brain by the cochlear nerve. Hearing, therefore, comprises a conductive phase that involves the external and middle ear, and a sensorineural phase that involves the inner ear and cochlear nerve. The auditory canal and the tympanic membrane are examined with the otoscope, a handheld instrument with a light source, a magnifier, and a disposable cone-shaped speculum. It is important to be familiar with the tympanic membrane landmarks (

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 Science Education: Essentials of Emergency Medicine and Critical Care

Central Venous Catheter Insertion: Subclavian Vein

JoVE Science Education

Source: James W Bonz, MD, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA

Central venous access is necessary in a multitude of clinical situations for hemodynamic monitoring, medication delivery, and blood sampling. There are three veins in the body that are accessed for central venous cannulation: the internal jugular, the subclavian, and the femoral vein. Central venous access via the subclavian vein has several advantages over other possible locations. The subclavian central venous catheter (CVC) placement is associated with lower infection and thrombosis rate than internal jugular and femoral CVC. Subclavian line can be placed quickly using anatomic landmarks and are often performed in trauma settings when cervical collars obliterate the access to the internal jugular (IJ) vein. The most significant disadvantage of the subclavian access is the risk of pneumothorax due to the anatomic proximity to the dome of the lung, which lies just superficial to the subclavian vein. In addition, in the event of an inadvertent arterial puncture, the access to the subclavian artery is impeded by the clavicle, which makes it difficult to effectively compress the vessel. Successful placement of the subclavian CVC requires good working understanding of the tar

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 JoVE Medicine

Evaluation of a Novel Laser-assisted Coronary Anastomotic Connector - the Trinity Clip - in a Porcine Off-pump Bypass Model

1Department of Cardiothoracic Surgery, University Medical Center Utrecht, 2Vascular Connect b.v., 3Department of Neurosurgery, University Medical Center Utrecht, 4Department of Experimental Cardiology, University Medical Center Utrecht


JoVE 52127

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 JoVE Immunology and Infection

Antibody Binding Specificity for Kappa (Vκ) Light Chain-containing Human (IgM) Antibodies: Polysialic Acid (PSA) Attached to NCAM as a Case Study

1Department of Neurology, Mayo Clinic, 2Mayo Clinic Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, 3Center for Regenerative Medicine, Neuroregeneration, Mayo Clinic, 4Division of Neonatal Medicine, Mayo Clinic, 5Department of Pediatric and Adolescent Medicine, Mayo Clinic


JoVE 54139

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 JoVE Immunology and Infection

Phenotypic Characterization of Macrophages from Rat Kidney by Flow Cytometry

1Renal, Vascular and Diabetes Research Lab, IIS-Fundaciòn Jiménez Dìaz, Autonoma University, 2Department of Physiology, Faculty of Medicine, Complutense University, 3Department of Immunology, Centro Nacional de Microbiologìa, Instituto de Salud Carlos III (ISCIII)


JoVE 54599

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 Science Education: Essentials of Emergency Medicine and Critical Care

Pericardiocentesis

JoVE Science Education

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

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