教育部教學實踐研究計畫成果報告(封面)

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【附件三】之 2 教育部教學實踐研究計畫成果報告格式

教育部教學實踐研究計畫成果報告(封面)

Project Report for MOE Teaching Practice Research Program (Cover Page)

計畫編號/Project Number：PMN1080073

學門專案分類/Division：醫護

執行期間/Funding Period：2019-08-01-2020-07-31

建立以手持式超音波輔助加強醫學生身體診察準確性里程碑計畫臨床醫學總論實習上

計畫主持人(Principal Investigator)：李百卿共同主持人(Co-Principal Investigator)：無

執行機構及系所(Institution/Department/Program)：國立臺灣大學醫學院內科

成果報告公開日期：

√

^立即公開

□

^延後公開(統一於 2022 年 9 月 30 日公開)

繳交報告日期(Report Submission Date)：2022 年 9 月 2 日

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建立以手持式超音波輔助加強醫學生身體診察準確性里程碑計畫 A milestone project to study the use of ultrasonography for enhancing physical

examination accuracy in medical students 一. 報告內文(Content)

1. 研究動機與目的(Research Motive and Purpose)

當前醫學生和畢業後醫師的訓練過程，在檢驗、影像醫學與電子病歷的蓬勃發展使用下，含有身體診察等的床邊教學與根據病史診察所做的臨床推理並未受到適當的重視。年輕醫師每日的工作時間大多坐在電腦螢幕前；看一位病患的時間，

根據研究只有 7.7 分鐘。許多臨床醫師也都感受到電子病歷的帶來的衝擊和改變，確實讓訓練中的住院醫師疏忽了身體診察的重要性。如何加強身體診察的能力，變成是當前醫學教育中重要的挑戰。

身體診察是醫師運用自己的感官、檢查器具等來檢查患者身體狀況的方法，其目的是收集患者身體的客觀資料，輔助病史、進行臨床推理。身體診察的方法涵蓋視診、觸診、叩診、聽診等。通常實行的方式是按照各器官系統，順序檢查，

但也可以依醫師認為有必要的部分直接加以檢查。檢查的內容，若要求完整則通常須包括以下檢查：生命徵象及意識狀態、頭頸部及眼耳鼻喉、心臟及周邊血管、胸部(乳房及肺臟)、腹部（包括肝臟、脾臟、腎臟、泌尿系統及生殖系統)、

肌肉骨骼關節、神經學(腦神經及周邊神經)的檢查。

身體診察所呈示的徵候是疾病的客觀標誌，當身體診察的徵候能肯定病史所顯示的機能性或構造性變化之時，最具診斷價值。有時候，身體診察徵候可能是疾病的唯一證據，在病史相互矛盾、混亂，或根本缺乏病史之時，往往只能依據身體診察來做初步的診斷推論。身體診察應該講究方法和技巧，雖然病史往往

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會將醫師的注意力引導到罹病的器官或是身體的某一部位去，但是施行身體診察時仍然必須巨細靡遺，並以客觀的方式從頭到腳施行檢查以便找出異常所在。

傳統上身體診察的診斷技巧是在經驗中鍛鍊出來的，身體診察絕不僅只是發現徵候的技術而已，還必須立即思考該徵候的臨床意義，並與病史詢問所得到的資料綜合判讀。身體診察的技巧能夠反映出醫師的思路。病人的徵候可能常常變化，一次的診察結果正常並未能保證在嗣後之診察也正常，所以每次看到病人，

都應視病情的需要重覆施行仔細的身體診察。

然而社會大眾及醫師本身皆認為在診斷工作方面，現在與過去有所差異：從過去重視身體診察、少用儀器，漸漸走向身體診察減少、依賴儀器。八成的住院病人雖然都喜歡並願意接受床邊教學及身體診察，但是醫學生的臨床教育在70 年代身體診察與床邊教學尚且佔了70%，到了 90 年代後卻只剩下 16% 甚至更低。

一位醫學博士Sandeep Jauhar M.D., Ph. D.在 2006 年的新英格蘭醫學期刊發表了一篇文章[1]，標題叫做 "身體診察已死" (The Demise of the Physical

Examination)。聊了一個案例並且提到現在醫生聽診器診斷能力的低落，比如說 1992 年在杜克大學醫學中心找了 63 位住院醫師，在安靜的空間聽三種常見心雜音。有1/2 無法辨認出二尖瓣閉鎖不全及主動脈閉鎖不全，有 2/3 無法辨認出二尖瓣狹窄。一年後，重複測試一次，結果還是一樣。所以現在身體診察的正確率，真是低落到無以復加的地步。

臨床醫師對於自己的身體診察能力沒把握，也就只能希望多用儀器檢驗來減少疏失，卻帶來了醫療費用高漲；沒有嚴謹的身體診察也就減少了和病人接觸機會，反而忽略了儀器檢驗不到的地方，導致診斷錯誤，讓病患久病不治。因此如何增加醫生身體診察的準確性，讓醫生用心於看診、溝通及身體診察等基本動

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作，以減少醫療浪費與支出，並提升醫療品質，形成此一良性循環，實在是迫切需要計畫執行的課題。

2. 文獻探討(Literature Review)

根據統計，美國已有多個的醫學院將超音波列為課程[2-5]，美國國家超音波課程也明列哪些領域需要教授[6]。證據顯示學習超音波能增進醫學生學習解剖及生理的知識及學習動機[7-9]。然而使用手持式超音波來做這方面的教學較少見，主要原因是臺式超音波的解析度佳且螢幕較大方便觀察。手持式超音波具有便宜、便利及容易購得等優勢，使用在醫學生每日的臨床教學更佳[10]。目前教導醫學生手持式超音波的文獻還很少，主要是研究醫學生使用超音波檢查某個器官問題的準確性[11-15]。這些器官包括心臟、肺臟、肝臟、膽囊、脾臟、腹水、腹主動脈、下腔靜脈、肌肉骨骼關節及甲狀腺。最常用於心臟功能不全的檢查，敏感度達0.88 而特異性達 0.86。目前尚未有適合醫學生學習的一致的標準協定，也沒有身診能力減退或經濟層面影響等長期研究。所以使用超音波來輔助加強醫學生身體診察是一個新的想法，報告的文獻只有集中在1-3 個器官驗證上[12,16]。

先導性研究

後學分別在2017 年及 2018 年邀請到 18 位醫學系五年級學生來接受「超音波輔助加強醫學生身體診察準確性訓練課程」。這18 位同學都已經完成完整的四年級身體診察課程。我們得到以下初步的結果：在測量方面身體診察與超音波測量相當接近，(以觸診主動脈大小而言)誤差平均為 0.3±0.4 公分。身體診察結果與超音波的一致性(Cohen's kappa)在訓練前為 0.6，在訓練前為 0.8。訓練前七成同學對身體診察的自信為還好、五五波：訓練後七成同學對身體診察的自信為有把握，

多數時能夠確定。

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1. 訓練後身體診察知識增加。

2. 訓練後身體診察實作頻率增加。

3. 研究問題(Research Question)

目前的醫學院臨床診斷課程已不太重視身體診察的技術，以致於也許住院醫師雖然可以通過國考的內科筆試，但並不一定證明他「徒手」做身體診察的技術是可靠的。雖然學生以及住院醫師強烈地希望在內科實習期間，把身體診察技術練

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好，但是他們在床邊所做的身體診察技術，已無法讓他們正確而可靠地把一些

「signs」看出來，或誘導出來。所以提出「手持式超音波輔助加強醫學生身體診察準確性訓練課程」來研究對學生學習效果的影響：使用手持式超音波能否增加身體診察的準確性？手持式超音波對學生身體診察的自信程度的影響？

學生叩診肝臟上緣平均需要 58 秒才能確定位置(左圖)，老師叩診肝臟上緣只要6 秒即能確定位置(右圖)，再用超音波驗證也只要 6 秒即能顯示正確位置(下圖)。

用超音波驗證正確位置時，同時講評解釋如何改善叩診技巧。

4. 研究設計與方法(Research Methodology)

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本計畫將建立一套新的「手持式超音波輔助加強醫學生身體診察準確性訓練課程」，課程時間是融入到醫學系四年級每星期五下午的臨床實習課程，將授課提前20 分鐘。每周五 13:00-13:20 由李百卿老師於大講堂，為全體同學作課前教育。

課程進行方式說明：

1. 在暑假期間，小組老師練習全部 10 個主題並攜帶手持式超音波回家練習 (有教師手冊輔助教學)。

2. 開學後，學生可下載講義輔助學習。鼓勵學生預習當周身體診察主題。

3. 第一堂課由李醫師簡報給同學知情同意，並請同意的同學在知情同意書簽名 (學生可以不同意，不影響上課權益或成績)。

4. 每周五下午 1:00 至 1:20 在 502 講堂由李醫師展示該周上課時驗證身體診察的主題。先由李醫師指導學生身體診察，然後再用超音波驗證診察的準確性。現場將由教學部支援將過程投影至大螢幕並錄影。

5. 1:30 至 5:00 實習課時再由小組老師以超音波驗證身體診察結果：以實作為主，學員互相執行身體診察後，由老師進行超音波驗證並給予即時回饋。在每次的實習課後請學生上網填寫學習問卷。

時間地點事由

1:00-1:20 502 講堂示範每組輪流請一位學生當受檢者

備有講義

1:30 前內科主任室組長領取各組專用超音波

1:30-5:00 病房討論室實習教學及超音波驗證

(請老師按學號儲存靜態影像, 做為驗證身診根據)

5:00 後 Zuvio 網站學生和老師填寫回饋建議

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各週課程進度是每週 1 個主題 1 小時, 共 10 周 10 個主題。學門包括心臟科、

胸腔科、內分泌科、腸胃科、及血液腫瘤科。驗證的範圍主要是可以由視診、觸診、叩診、聽診等得到的身體診察結果。如下圖所示，視診包括測量頸靜脈壓力及身體水分評估；觸診則是觸摸頸部淋巴結、甲狀腺、腹主動脈大小；叩診有心臟、肝臟、脾臟評估是否變大、是否有腹水；聽診有肺音等。

本研究計畫是以學生整體成績與前兩屆同學相比較，並沒有對個別同學打成績，

所以學生的學習、權益、及成績評量公平性是不會受到影響。

評估成效的指標：評估指標有三，分述如下：

一、formative assessment 是以手持式超音波得到的數據為黃金標準，與學生身體診察的數據在使用訓練課程前後的比較。目的是能修正同學觀察及手作的技能，

以提高身診準確性為目標。

二、short-term summative assessment 在四年級上學期期末時，將統一由內科進行四年級臨床實習測驗心臟、胸腔及腹部等身體檢查，將這部分總成績與前二屆

週次日期科目診察方式超音波驗證

9/6 W5 教師展示全全

第1週 9/13 W5 中秋節第2週 9/20 W5 知情同意

第3週 9/27 W5 1. 淋巴結觸診淋巴結

第4週 10/4 W5 2. 甲狀腺觸診甲狀腺

第5週 10/11 W5 調整放假

第6週 10/18 W5 3. 頸靜脈視診頸靜脈

第7週 10/25 W5 4. 心臟大小視診, 觸診及叩診 (PMI) 心尖位置第8週 11/1 W5

第9週 11/8 W5 5. 身體水分視診及觸診 (Eyes, mouth, axilla, skin) 下腔靜脈第10週 11/15 W5 校慶

第11週 11/22 W5 6. 肺部聽診肺部

第12週 11/29 W5 7. 肝肺交界叩診肝肺交界

第13週 12/6 W5 8. 脾臟大小叩診 (Castell sign) Echo Castell sign 第14週 12/13 W5 9. 腹水叩診 (Fluid wave, shifting dullness) Morrison pouch

第15週 12/20 W5 10. 腹主動脈觸診腹主動脈

第16週 12/27 W5 SP 第17週 1//3 W5 期末考評

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比較有無差異，作為短期成效的一個指標。

三、long-term summative assessment 比較六年級國家考試-客觀結構式臨床測驗 (OSCE)總成績與前二屆比較有無差異，作為長期成效的一個指標。

目的超音波輔助身體診察 成效評估

時程對象

醫四上學期 同儕練習

醫四上期末測驗 醫六國考OSCE

視診超音波驗證

頸靜脈診察身體水分診察深部靜脈診察

心臟、肺部、腹部 診察總體成績

身體診察(OSCE) 測驗總體通過率

觸診超音波驗證

甲狀腺診察 淋巴結診察腹主動脈診察

叩診超音波驗證

心臟大小診察 肝臟大小診察脾臟大小診察腹水診察

聽診超音波驗證

肺音診察

5. 教學暨研究成果(Teaching and Research Outcomes) (1) 教學過程與成果

教學過程方面:小組老師反應舉例：

「超音波驗證加身體診察過程可能會花到快一小時！希望之後練習能縮短時間！」

「不知道是否有可能提供淋巴結腫大的病人。」

「學生似乎對目前身體診察的部分會有過度期待一定會有發現。」

課程安排方面: 小組老師反應舉例：

「學生們，很快抓到訣竅。」

「課程設計和身體診察完整配合，對學生是很好的學習方式。」

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「利用簡單的方式讓學生確認身體診察的結果，很好的教案設計。」

事實上，透過這樣的方式學習，學生普遍認為有學會教授的課程內容。

(2) 教師教學反思

計劃本身執行的困難度適中，對學生和老師都是一個嶄新的教學相長的經驗。老師能更明瞭每位同學的身診能力，更能給予適切性的指導。

學生和小組老師的關係更密切，能更大方地和老師求教。銜接這個計劃，將跨入「以手持式超音波驗證臨床身體診察」。在這個計畫裡，每位小組老師將直接在病人身上驗證學生的身體診察結果。學生將可獲得身體診察的「實戰」能力及驗證。

(3) 學生學習回饋 學生意見舉例:

滿意:「淋巴結觸摸比較困難，超音波影像的確認比較能增添信心。」

對身診有問題: 「一直摸都摸不出來耶。」

對超音波有問題:「可以先給一些範例的超音波圖片進行教學。」

不滿意:「1300-1320 的課程可以刪掉或改小組進行，大班效果不太好，

很難理解跟吸收」

其他:「很棒！希望以後可以繼續下去。不過要求所有人都做可能會浪費時間」

6. 建議與省思(Recommendations and Reflections)

現代醫學，隨著科學技術的精進，檢驗科技的進步和電子病歷的發展尤為迅速。精密儀器不斷推出，以至於臨床醫師過度仰賴儀器的診斷，忽略問診和身體診察等的診斷技巧。一方面花在真正照顧病人和看病人的時間越來越少，另一方面檢驗帶來的醫療給付和疏失帶來的醫療訴訟卻越來越多。臨床醫師對於自己的身體診察能力沒把握是導致此惡性循環的重要原因之一。

超音波具有高敏感度及精確度已成為診斷疾病的主要工具之一。但因為醫院

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用臺式超音波儀器體積龐大移動不便且價格昂貴，必須於醫院才能進行檢查。電腦科技的進步，手持式超音波不僅體積大大縮小且具有大型超音波儀器的診斷精確度，藉由手持式超音波體積小移動便利，不僅可就地驗證身體診察結果，且可加強推展床邊教學。

身體診察為各科入門的基本檢查，有鑑於目前已漸被忽視且檢查準確性不可得知，乃籌劃此一計畫，希望能減少初學的摸索並提昇醫療教學服務品質。目的就是要醫學生在具備嚴謹的身診能力的醫師指導下學習熟悉身體診察的技巧，並以超音波驗證身體診察的準確性，從而對於自己進行的身體診察具有信心，同時在日常的臨床工作中確實實地看病人，為日後之醫療專業執行奠立良好的基礎。

二. 參考文獻(References)

1. Jauhar S. The demise of the physical exam.N Engl J Med. 2006;354:548-551.

2. Lapostolle F, Petrovic T, Lenoir G, Catineau J, Galinski M, Metzger J, Chanzy E, Adnet F.

Usefulness of hand-held ultrasound devices in out-of-hospital diagnosis performed by emergency physicians. Am J Emerg Med. 2006;24:237-242.

3. Kobal SL, Trento L, Baharami S, Tolstrup K, Naqvi TZ, Cercek B, Neuman Y, Mirocha J, Kar S, Forrester JS, Siegel RJ. Comparison of effectiveness of hand-carried ultrasound to bedside cardiovascular physical examination. Am J Cardiol. 2005;96:1002-1006.

4. Cawthorn TR, Nickel C, O’Reilly M, Kafka H, Tam JW, Jackson LC, Sanfilippo AJ, Johri AM. Development and evaluation of methodologies for teaching focused cardiac ultrasound skills to medical students. J Am Soc Echocardiogr. 2014;27:302-309.

5. Fox JC, Schlang JR, Maldonado G, Lotfipour S, Clayman RV. Proactive medicine: the

“UCI 30,” an ultrasound-based clinical initiative from the University of California, Irvine.

Acad Med. 2014;89:984-989.

6. Baltarowich OH, Di Salvo DN, Scoutt LM, Brown DL, Cox CW, DiPietro MA, Glazer DI, Hamper UM, Manning MA, Nazarian LN, Neutze JA, Romero M, Stephenson JW,

Dubinsky TJ. National ultrasound curriculum for medical students. Ultrasound Q. 2014;30:13- 19.

7. Sweetman GM, Crawford G, Hird K, Fear MW. The benefits and limitations of using ultrasonography to supplement anatomical understanding. Anat Sci Educ. 2013;6:141-148.

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8. Tshibwabwa ET, Groves HM. Integration of ultrasound in the education programme in anatomy. Med Educ. 2005;39:1148.

9. Hammoudi N, Arangalage D, Boubrit L, Renaud MC, Isnard R, Collet JP, Cohen A, Duguet A. Ultrasound-based teaching of cardiac anatomy and physiology to undergraduate medical students. Arch Cardiovasc Dis. 2013;106:487-491.

10. Sicari R, Galderisi M, Voigt JU, Habib G, Zamorano JL, Lancellotti P, Badano LP. The use of pocket-size imaging devices: a position statement of the European Association of Echocardiography. Eur J Echocardiogr. 2011;12:85-87.

11. Mai TV, Ahn DT, Phillips CT, Agan DL, Kimura BJ. Feasibility of remote real-time guidance of a cardiac examination performed by novices using a pocket-sized ultrasound device. Emerg Med Int. 2013;2013:627230.

12. Andersen GN, Viset A, Mjolstad OC, Salvesen O, Dalen H, Haugen BO. Feasibility and accuracy of point-of-care pocket-size ultrasonography performed by medical students. BMC Med Educ. 2014;14:156.

13. Gogalniceanu P, Sheena Y, Kashef E, Purkayastha S, Darzi A, Paraskeva P. Is basic emergency ultrasound training feasible as part of standard undergraduate medical education? J Surg Educ. 2010;67:152-156.

14. Bonnafy T, Lacroix P, Desormais I, Labrunie A, Marin B, Leclerc A, Oueslati A, Rolle F, Vignon P, Aboyans V. Reliability of the measurement of the abdominal aortic diameter by novice operators using a pocket-sized ultrasound system. Arch Cardiovasc Dis. 2013;106:644- 650.

15. Panoulas VF, Daigeler AL, Malaweera AS, Lota AS, Baskaran D, Rahman S, Nihoyannopoulos P. Pocket-size hand-held cardiac ultrasound as an adjunct to clinical examination in the hands of medical students and junior doctors. Eur Heart J Cardiovasc Imaging. 2013;14:323-330.

16. Stokke TM, Ruddox V, Sarvari SI, Otterstad JE, Aune E, Edvardsen T. Brief group

training of medical students in focused cardiac ultrasound may improve diagnostic accuracy of physical examination. J Am Soc Echocardiogr. 2014;27:1238-1246.

三. 附件(Appendix)

與本研究計畫相關之研究成果資料，可補充於附件，如學生評量工具、訪談問題等等。附上學生課前講義。

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Palpate the neck lymph nodes

Lee, Bai-Chin 2019 Key teaching points

The following findings increase the probability of severe disease: fixed nodes, large nodes (length x width ≥ 9 cm²), weight loss, supraclavicular adenopathy, and (stony) hard nodes. Normal lymph nodes are not palpable, but nodes enlarged from prior infection may be palpable. In children up to 12 years of age, shotty cervical nodes up to 1 cm in diameter are almost always felt in the cervical region, the axilla, and the inguinal area. In adolescents and adults, palpable inguinal lymph nodes are very common and may be of little significance.

Techniques of Examination

Using the pads of your index and middle fingers, press gently, moving the skin over the underlying tissues in each area. The patient should be relaxed, with the neck flexed slightly forward and, if needed, turned slightly toward the side being examined. You can usually examine both sides at once, noting both the presence of lymph nodes as well as asymmetry. For the submental node, however, it is helpful to feel with one hand while bracing the top of the head with the other. When students feel a palpable node, make a mark on the skin and start a validation by ultrasound.

Feedback

Student response Teacher feedback

I cannot palpate anything. 1. Make sure the location is right.

2. Palpation must be light, or small nodes will escape notice.

3. Look for asymmetry by palpating both sides with both hands.

4. Most palpable nodes are superficial nodes. The only deep nodes detectable by bedside

examination are the deep cervical nodes and the axillary nodes.

I can palpate a node, but why the ultrasound shows nothing?

Occasionally, one may mistake a band of muscle or an artery for a lymph node.

Unlike a muscle or an artery, one should be able to roll a node in two directions: up and down, and side to side. Neither a muscle nor an artery will pass this test.

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Sequence for examining cervical lymph nodes.

1. Preauricular—in front of the ear

2. Posterior auricular—superficial to the mastoid process 3. Occipital—at the base of the skull posteriorly

4. Tonsillar—at the angle of the mandible

5. Submandibular—midway between the angle and the tip of the mandible.

6. Submental—in the midline a few centimeters behind the tip of the mandible.

7. Superficial cervical—superficial to the sternocleidomastoid.

8. Posterior cervical—along the anterior edge of the trapezius.

9. Deep cervical chain—deep to the sternocleidomastoid and often inaccessible to examination. Hook your thumb and fingers around either side of the sternocleidomastoid muscle to find them.

10. Supraclavicular—deep in the angle formed by the clavicle and the sternocleidomastoid. If you feel supraclavicular lymph nodes, a thorough workup is warranted.

Palpate preauricular lymph node Palpate submandibular LN Palpate supraclavicular LN

Palpate epitrochlear lymph node

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Interpretation

Note lymph nodes size, shape, delimitation (discrete or matted together), mobility, consistency, and any tenderness. Small, mobile, discrete, non-tender nodes, sometimes termed “shotty,” are frequently found in normal people. Describe enlarged nodes in two dimensions, maximal length, and width, for example, 1 cm

× 2 cm. Also note any overlying skin changes (erythema, induration, drainage, or breakdown).

Size Insignificant if < 2cm

In axilla and inguinal, insignificant if < 3cm In the supra-claviclar fossa > 1cm is significant

Shape Oval flat (insignificant) vs. round sphere (infection or malignancy)

Delimitation Discrete vs. matted together (classically malignancy & granulomatous infection) Mobility Mobile (classically infection) vs. immobile (classically malignancy)

Consistency soft (insignificant), rubbery (classically lymphoma), hard (classically malignancy &

granulomatous infection)

Tender Tender (classically infection) vs. non-tender (classically malignancy)

Reference

Bates’ guide to physical examination and history taking, 20^th edition, p259-261 Evidence-based physical diagnosis, 4^th edition, chapter 27.

Stanford 25: https://stanfordmedicine25.stanford.edu/the25/lymph.html Video

https://youtu.be/rijL9bDrtPk https://youtu.be/IOeeuIZSnig https://youtu.be/PK0LPLB1tv0

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Ultrasound Validation 1. Choose the student’s ID.

2. Apply gel on a linear probe.

3. Put the probe on the mark of the skin with a cephalic direction and then a transverse direction.

Please refer to Example 1 and 2. Lymph nodes in the neck are oval or ellipsoid in shape. Within the node, there is generally a hypoechoic marginal zone, which can be distinguished from the central hyperechoic hilar region (the medullary sinuses with blood vessels and efferent lymph vessels) 4. Freeze the screen.

5. Make an annotation “Y,” if the student feels a palpable node.

Make an annotation “N,” if the student does not feel a palpable node.

6. Save the image.

Impalpable lymph node (deep, < 1cm, ovale) Palpable lymph node (superficial, >1cm, round)

Split screen, right side of the neck, level III. Lying between the internal jugular vein (VJI) and the common carotid artery (ACC) is an enlarged oval reactive lymph node; it has an L/S ratio of 2.0, is well-demarcated, and shows the “hilar sign.” A pinecone-shaped echogenic structure protruding from the center of the node can be seen in

grayscale images. It is sometimes referred to as the

“hilar sign” or “hilus sign” and is a normal part of the lymph node morphology. The absence of this hyperechoic central structure in the hilar region may be considered a criterion for malignancy.

Right side of the neck, transverse, level II. An oval lymph node in acute lymphadenitis

colli (i.e., cervical); the node has a delicate internal echo pattern with well-defined margins and measures 30 mm × 15 mm in both short-axis diameters.

Video

https://youtu.be/4z6I3yGVS-M

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A schematic representation of morphological changes in metastases. These morphological transformations within a lymph node illustrate sonographic findings of malignancy.

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Palpate the thyroid gland

The important landmarks for locating the thyroid gland are the V at the top of the thyroid cartilage (the laryngeal prominence of the thyroid cartilage) and the cricoid cartilage.

1. Put your finger on tip of your chin (mentalis).

2. Slide finger down the midline and the first hard structure you hit is the top of the thyroid cartilage.

3. Run your finger down the prow or the free edge of the thyroid cartilage (Adam's apple).

4. The next thing you hit is the cricoid cartilage (and see if you can get your fingernail in between the thyroid and cricoid cartilage–that is the cricothyroid membrane which is where a patent airway during certain life-threatening situations can be established).

5. Below the cricoid ring are the first two rings of the trachea, and the ISTHMUS of the thyroid overlies those two rings.

Palpation of the thyroid may proceed from the patient’s front or back, whichever is most comfortable and effective for the clinician, because studies fail to show either method to be superior. Because the thyroid and trachea are firmly attached by ligaments and must move together, inspection and palpation as the patient swallows helps to distinguish thyroid tissue from other neck structures.

Steps for palpating the thyroid gland (anterior approach):

1. Ask patient to flex neck slightly forward and relax.

2. Go through the landmarks as above.

3. Place thumbs of both hands just below cricoid cartilage so that left and right thumbs meet on the patient’s midline. Place digits posterior to patient’s neck and flatten both thumbs against the neck.

4. Use thumb pads, not tips, to palpate.

5. Identify the isthmus.

6. Gently draw thumbs laterally 1-2cm.

7. Gently palpate lateral lobes.

8. NOW ask patient to swallow (give them a glass of water if possible).

9. Assess for asymmetrical elevation of lobes (suggests nodularity).

10. When you are done with above, move to next phase, which is displacing the soft tissues on one side to the midline while assessing for size with the other hand.

11. Displace the trachea to subject’s right with the fingers of your right hand; with the left-thumb, palpate laterally for the right lobe of the thyroid in the space between the displaced trachea and the relaxed sternocleidomastoid.

12. Repeat in opposite direction.

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Interpretation

Goiter = Thyroid Enlargement

World Health Organization (WHO) classification:

Grade 0: No goiter is palpable or visible.

Grade 1: palpable goiter, not visible when neck is held in normal position.

Grade 2: a clearly swollen neck that is consistent with a goiter on palpation.

Grade 1: palpable goiter, not visible Grade 2: palpable and visible

Diffuse Enlargement: isthmus and lateral lobes, no nodules. Grave’s disease, Hashimoto’s thyroiditis, endemic goiter

Single node: Cyst, benign tumor, false positive (only one nodule of multinodular goiter detected).

Elevates index of suspicion for malignancy: Assess for risk factors: radiation exposure, hardness, rapid growth, fixation to surrounding tissue, cervical LAD, male, others.

Multinodular Goiter (iodine deficiency)

Consistency, tenderness, bruit

Soft in Graves’ disease and may have bruit.

Firm in Hashimoto’s thyroiditis, malignancy, & benign and malignant nodules.

Tender in thyroiditis.

Systolic or continuous bruit may be heard over lateral lobes in hyperthyroidism.

Caveats and common errors

The thyroid cartilage, despite its name, is not where the gland is situated.

The thyroid size is not associated with its function. A goiter can be present in hyperthyroidism, hypothyroidism, or a euthyroid state.

Reference

Stanford 25: https://stanfordmedicine25.stanford.edu/the25/thyroid.html

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Ultrasound Validation

1. The subject should be supine.

2. Choose the student’s ID.

4. Place the transducer below the cricoid cartilage with the marker pointed toward the patient’s right.

5. The maximum width and depth diameters are determined. The two thyroid lobes are

measured separately. The right lobe tends to be slightly larger than the left.

6. Freeze the screen.

7. Make an annotation “Y”, if the student feel a palpable goiter.

Make an annotation “N”, if the student does not feel a palpable goiter.

8. Save the image.

Interpretation

Goiter is present whenever the transverse or AP diameter exceeds 2 cm or when parenchyma extends anterior to the carotid artery

each lobe normally measures:

length: 4-7 cm; width or depth: <2 cm; isthmus measures <=0.5 cm deep

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Palpable ultrasound findings Palpable

Depth or width >=2cm parenchyma extends anterior to the carotid artery

Superficial nodule or nodule > 1cm Heterogeneous

Pyramidal lobe Impalpable deep nodule < 1cm

Video

https://youtu.be/J9eaYftUgE4 https://youtu.be/zozD2x2Ll4Q

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Inspect the jugular vein

To estimate the level of the JVP, teach to find the highest point of oscillation in the internal jugular vein or, alternatively, the point above which the external jugular vein appears collapsed. Either the external or internal jugular veins may be used to estimate pressure because measurements in both are similar. Identify the sternal angle (angle of Lewis), which is the standard reference point.

The external jugular vein is easier to visualize than the internal jugular vein. The pulsations of the internal jugular vein are beneath the sternocleidomastoid muscle and are visible as they are transmitted through the surrounding tissue. The internal jugular vein itself is not visible.

Because the right internal jugular vein is straighter than the left, only the right jugular veins are evaluated.

However, If you cannot clearly define the JVP on the right internal jugular, examine the left.

Make your first goal just to see a pulsation, and then decide if it is arterial or venous by applying the following criteria to identify venous waves:

1. Venous wave is bifid, flicking like a snake's tongue.

2. It rises when you lower the head of the bed and sinks when you raise the head of the bed.

3. It changes with respiration, more prominent (increased RA volume) but sinking into the chest with inspiration.

4. It is rarely palpable.

5. Pulsations eliminated by light pressure on the vein just above the sternal end of the clavicle.

Steps for measuring the jugular vein pressure:

1. Get the patient to relax, raise the bed so you are not straining.

2. Take the pillow away; the waveforms are often better seen with the head lying directly against the bed.

3. Position the neck until you have the best view. Raise the head of the bed or examining table to about 30°. Turn the patient’s head slightly away from the side you are inspecting.

4. Make sure the room is well lit, or use tangential lighting.

5. Make your first goal just to see a pulsation. If necessary, raise or lower the head of the bed until you can

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see the oscillation point of the internal jugular venous pulsations in the lower half of the neck.

6. Focus on the right internal jugular vein. Look for pulsations in the suprasternal notch, between the attachments of the SCM muscle on the sternum and clavicle, or just posterior to the SCM.

7. Identify the highest point of pulsation in the jugular vein. Make a mark on the skin and start a validation by ultrasound.

8. Extend a ruler horizontally from this point and a centimeter ruler vertically from the sternal angle, making an exact right angle. Measure the vertical distance in centimeters above the sternal angle where the horizontal object crosses the ruler and add to this distance 5 cm, the distance from the sternal angle to the center of the right atrium. The sum is the JVP.

Step 4-7 Step 8

Interpretation

The jugular venous pressure is abnormally elevated if

1. The top of the neck veins are more than 3 cm above the sternal angle

2. The JVP exceeds 8 cm water using the method of Lewis (i.e., > 3 cm above the sternal angle + 5 cm)

The highest point of venous pulsations may lie below the level of the sternal angle. Under these circumstances, venous pressure is not elevated and seldom needs to be measured.

Commonly, a prominent pulsation is mistaken for that of the carotid artery rather than of the JVP. To

differentiate, press on the mid-abdomen while watching the neck. The JVP should rise in all individuals with this maneuver; whereas a carotid pulsation should not change.

Reference

Stanford 25: https://stanfordmedicine25.stanford.edu/the25/nvwf.html

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1. The subject should be supine and keep the same position of physical examination.

4. Put the probe on the mark of the skin with a cephalic direction AND the top of transducer is just at the mark.

5. Freeze the screen

6. Make an annotation “Y,” if the student can find the highest point of oscillation in the internal jugular vein or, alternatively, the point above which the external jugular vein appears collapsed.

Make an annotation “N,” if the student can not find either one.

7. Save the image.

The following US picture is an expected feature.

The internal jugular vein (IJV) is shown in longitudinal view (left is cephalad). The skin surface is at the top of the figure and the solid arrow shows the point of vein collapse, which should be matched with the mark location

(Optional) Now, if you turn the transducer direction at 90 degree counterclockwise (transverse view), you will see the smallest lumen size of internal jugular vein (arrow).

Video

https://youtu.be/AWxbAg0E3E4 https://youtu.be/y-ZxU_jADNQ

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Percuss the apical impulse

To detect the cardiomegaly, teach to perform light indirect percussion in the left fifth interspaces from the anterior axillary line with the patient in the supine position. Percussion dullness distance of less than 10.5 cm from the mid-sternal line in the left fifth intercostal space decreases the probability of cardiomegaly.

Assess the location with the patient supine because the left lateral decubitus position displaces the apical impulse to the left.

Locate two points: the 5th interspace, which gives the vertical location, and the distance in centimeters from the mid-sternal line, which gives the horizontal location.

*For the midclavicular line, use a ruler to mark the midpoint between the sternoclavicular and acromioclavicular joints so that other clinicians can reproduce your findings.

Techniques of Percussion

Hyperextend the middle finger of your left hand, known as the pleximeter finger. Press its distal interphalangeal joint firmly on the chest surface to be percussed.

Position the right forearm quite close to the surface, with the hand cocked upward. The middle finger should be partially flexed, relaxed, and poised to strike.

With a quick, sharp but relaxed wrist motion, strike the pleximeter finger with the right middle finger, called the plexor finger.

At each position in the interspace, two light blows are delivered with the plexor finger.

Position of the right hand ready to percuss. Note that the thumb and second, fourth, and fifth fingers are not touching the chest wall.

Location of the fingers after striking. Note that the motion is from the wrist.

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Steps for locating the apical impulse by percussion:

1. Percussion is begun in the left anterior axillary, and the pleximeter finger is moved medially along the interspace in 1.0-cm increments until a dull percussion note is encountered.

2. The pleximeter finger is then moved lateral to this point and percussion is repeated, moving medially in 0.5-cm increments until a dull note is encountered.

3. Dullness is distinguished from resonance both by the change in sound and by the decreased chest wall vibration sensed by the pleximeter finger at the time of impact by the plexor finger.

4. Make a mark on the skin and start a validation by ultrasound.

5. The distance from the midsternal line to the apical impulse is recorded.

Percuss Measure

Interpretation

A percussion dullness distance of greater than 10.5 cm in the left fifth intercostal space has a sensitivity of 91.3% and a specificity of 30.3% for detecting increased left ventricular end-diastolic volume (LVEDV) or left ventricular mass, and has a sensitivity of 94.4% and a specificity of 67.2% in detecting cardiomegaly.

Each percussion blow should strike the same part of the pleximeter with identical force. The consistent technique is important because both the percussion force and the pleximeter govern the percussion sound produced. Lighter strokes produce sounds that are duller than those produced by stronger strokes. Lifting the pleximeter finger, even slightly, can transform a resonant note into a dull one.

Reference

Stanford 25: http://stanfordmedicine25.stanford.edu/the25/precordial.html

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3. Apply gel on a phase array probe.

4. Put the probe on the mark of the skin with a transverse direction AND the top of

transducer is just at the mark.

6. Make an annotation “Y,” if the student can find the location of apical impulse

Make an annotation “N,” if the student can not find it.

7. Save the image.

Apical four-chamber transducer placement:

Place the transducer on the mark with the

transducer pointed toward the student’s left elbow.

Cardiac chambers are as follows: left atrium (a), left ventricle (b), right atrium (c), and right ventricle (d)

Heart apex US finding (find the PMI) Lung US finding (miss the PMI)

Video

https://youtu.be/x4pBrgWzp18 https://youtu.be/_xXJgRVC0pU

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Access the hypovolemia

In elderly patients with acute illness, five physical findings accurately detect hypovolemia: sunken eyes, slow capillary refill, abnormal skin turgor (subclavicular space), dry oral mucosa, and dry axilla. The absence of tongue furrows and presence of normal skin turgor decrease the probability of hypovolemia.

Techniques of Assessment (From top to toe) Sunken eyes

Sunken eyes are considered to be present when the bilateral eyeballs seem abnormally sunken.

Dry mouth

Dry mouth is considered as present when both mucous

membrane (froth saliva, right uppper) and tongue (furrows, right lower panel) are dry by inspection.

Abnormal skin turgor

Abnrormal skin turgor refers the slow return of skin to its normal position after being pinched between the examiner’s thumb and forefinger. Pull up 2.5 to 5 cm of skin over the subclavicular area and release it. The persistence of skin tenting for 3 or more seconds after 3 seconds of pinching is defined as abnormal.

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Dry axilla

Dry axilla is examined by palpating bilateral axillary skin using the examiner’s second to fifth fingers.

Slow capillary refill

Capillary refill time is determined by compressing the distal phalanx of the patient’s middle finger, positioned level with the heart, for 5 seconds and then timing the return of normal color to the finger. The upper upper limit of normal refill time is set at 2 seconds

Interpretation

Be sure that the ambient temperature is warm. A cool environment can cause peripheral vasoconstriction and alter the results of the assessment.

Reference

Evidence-based physical diagnosis, 4^th edition, chapter 11 Sapira's Art & Science of Bedside Diagnosis, 5^th edition, p. 433

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3. Apply gel on a curvilinear or phased array probe.

4. Put the probe above or below xiphoid process little right from midline and the probe marker is pointing toward sternal notch.

5. Fan probe laterally to view the IVC draining and identify it draining into the right atrium.

6. The liver's behind (caudate lobe) compressing IVC at one level is normal .

7. Standard measuring point is 3 cm below right atrium. Measure the expiratory IVC diameter.

9. Make an annotation “Y,” if the student can find one of the five signs

Make an annotation “N,” if the student can not find any.

10. Save the image.

Pearls to improve view window

View improves with the patient taking a deep inspiration Interpretation

Inferior vena cava (IVC) is normally 1.5 to 2.5 cm in diameter (measured 3 cm from right atrium) IVC <1.5 cm suggests volume depletion

IVC >2.5 cm suggests volume overload Pearls and Pitfalls

1. Aorta can be confused for IVC, ensure you visualize the vessel entering the atrium.

2. Ensure the vessel is viewed in full longitudinal axis as being off-center will give falsely narrow measurements.

Video

https://youtu.be/qHWLFfXtGn8 https://youtu.be/zcgD5K6QL2s

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Auscultate the breath sounds

There are two types of breath sounds: (1) vesicular breath sounds, which are normally heard over the posterior chest, and (2) bronchial breath sounds, which are normally heard over the trachea and right apex.

Knowledge of pulmonary anatomy helps to recognize auscultated sounds from pulmonary sources.

Picture the lungs and their fissures and lobes

on the chest wall. Anteriorly, the apex of each lung rises approximately 2 to 4 cm above the inner third of the clavicle. The lower border of the lung crosses the 6th rib at the midclavicular line and the 8th rib at the midaxillary line. Posteriorly, the lower border of the lung lies at about the level of the 10 spinous process.

The major fissure can be located by drawing a line from the T2/3 spinous process to where the 6th rib meets the midclavicular line.

Easier method to determine major fissure: Simply ask the patient to put their hands over their head. The scapula will rotate externally and its medial border will outline the major fissure.

The minor fissure can be approximated by drawing a horizontal line from the 4th rib attachment of the sternum to the major fissure in the midaxillary line near the 5th rib.

The inferior tip of the scapula is another useful bony landmark; it usually lies at the level of the 7th rib or interspace.

The spinous processes of the vertebrae are also useful landmarks. When the neck is flexed forward, the most protruding process is usually the vertebra of C7. If two processes are equally prominent, they are C7 and T1.

Techniques of Auscultation

Before beginning auscultation, ask the patient to cough once or twice.

Listen to the breath sounds with the diaphragm of your stethoscope after instructing the patient to breathe deeply through an open mouth.

Always place the stethoscope directly on the skin.

Start at the apices and compare each side with the other.

Use the ladder pattern , moving from one side to the other and comparing symmetric areas of the lungs. Listen to at least one full breath in each location.

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Ladder pattern (Z line)

Types of Breath Sounds

Breath sounds are heard over most of the lung fields. They consist of an inspiratory phase followed by an expiratory phase. There are four types of normal breath sounds:

Interpretation

If bronchovesicular or bronchial breath sounds are heard in locations distant from those listed, suspect replacement of air-filled lung by fluidfilled or consolidated lung tissue. In patients with cough and fever, bronchial breath sounds increase the probability of pneumonia (LR =3.3).

Bedclothes, paper gowns, and even chest hair can generate confusing crackling sounds that interfere with auscultation. For chest hair, press harder or moisten the hair.

Reference

https://stanfordmedicine25.stanford.edu/the25/pulmonary.html https://youtu.be/WbZl5ltG-y0

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1. The subject should be sitting or supine.

3. Apply gel on a curvilinear probe.

4. Place the transducer vertically with the marker pointed cephalad.

5. Begin by evaluating for lung sliding.

6. Evaluate for A-lines and B-lines.

7. Image the lung field with abnormal bronchial sounds. Image at least two lung fiels if no abnormal brochial sounds aulscultated.

8. Freeze the screen.

9. Make an annotation “Y,” if the student can find abnormal bronchial breath sounds.

Make an annotation “N,” if the student can not find abnormal bronchial breath sounds.

10. Save the image.

A-lines B-lines

A-lines: reverberation artifact due to the reflection of ultrasound waves from the pleura seen as multiple echogenic horizontal lines (repetitions of the pleural line) separated by a distance equal to the thickness of the chest wall.

A-lines will be seen throughout normal lung parenchyma.

They are often absent in the setting of interstitial disease, consolidation, and pleural effusions.

B-lines: ray-like or comet-tail vertical lines that extend from the pleural line down to the bottom of the screen without fading.

B-lines will move synchronously with lung sliding.

Generated by alveoli.

It is normal to have up to three B-lines in one field of view. Greater than three is abnormal and can be seen with pulmonary edema and conditions that cause thickened inter-alveolar soft tissue.

Video

https://youtu.be/RBgGA_rqVvE https://youtu.be/k6CgiTmgjIw

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B-line reference:

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Percuss the lung-liver border

Lee, Bai-Chin 2019 Key learning/teaching points

The purpose of liver percussion is to measure the liver size. Measure the vertical span of liver dullness in the right midclavicular line after carefully locating the midclavicular line to improve accurate measurement.

Steps for locating the lung-liver border by percussion:

1. Starting in the midclavicular line at about the 3rd intercostal space, lightly percuss and move down.

2. Percuss inferiorly until dullness denotes the liver's upper border (usually at 5th intercostal space).

3. Make a mark on the skin and start a validation by ultrasound.

Steps for locating the lower border of the liver by percussion:

4. Resume percussion from below the umbilicus on the midclavicular line in an area of tympany.

5. Percuss superiorly until dullness indicates the liver's inferior border.

6. Measure span in centimeters.

Special technique—auscultatory percussion—scratch test

Sratch test is frequently used to locate the lower border of the liver. The moment the clinician’s percussing digit crosses the border of the liver and begins to strike abdominal wall over the liver, the sound heard through the stethoscope becomes louder.

Percuss Scratch

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Interpretation

*Elevated lung-liver border (higher than 4^th ICS): right pleural effusion, consolidated lung.

*Depressed lung-liver border (lower than 6^th ICS): emphysema

*Liver span along the midclavicular line: normally 6-12cm.

The span of liver dullness is increased when the liver is enlarged. The span of liver dullness is decreased when the liver is small, or when there is free air below the diaphragm, as from a perforated hollow viscus.

Use a light to moderate percussion strike, because a heavier strike can lead to underestimates of liver size.

COPD may depress diaphragm and hence depress liver borders, but not span.

3. Apply gel on a phase array probe.

4. Put the probe on the mark of the skin with a transverse direction AND the top of transducer is just at the mark.

6. Make an annotation “Y,” if the student can find the CORRECT location of lung-liver border.

Make an annotation “N,” if the student can not find it.

7. Save the image.

Liver (The dome area of the right hepatic lobe near the diaphragm)

Lung

Reference

Stanford 25: http://stanfordmedicine25.stanford.edu/the25/liver.html Video

https://youtu.be/48nzLXnEHvg https://youtu.be/J5gRFeZ7cZU

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Percuss the spleen (Castell’s sign)

The purpose of both palpation and percussion of the spleen is to look for splenic enlargement. However, percussion may indicate but does NOT confirm splenomegaly.

Steps for detection of splenomegaly by palpation:

1. Start in RLQ (because the spleen enlarges in the inferior anteromedial direction, sometimes as far as the RLQ.).

2. Get your fingers set then ask patient to take a deep breath. Don’t dip your fingers or do anything but wait.

3. When patient expires, take up new position.

4. Note lowest point of spleen below costal margin, texture of splenic contour, and tenderness.

5. Repeat with the patient lying on the right side with legs somewhat flexed at the hips and knees. Gravity may bring spleen within reach.

Steps for detection of splenomegaly by percussion:

Negative Castell’s sign Positive

Percuss the lowest interspace in the left anterior axillary line (Castell’s point, usually the 8^th or 9^th ICS). This area is usually tympanitic ( if the percussion note is dull, the test is positive¹). Then ask the patient to take a deep breath, and percuss again. When spleen size is normal, the percussion note usually remains

tympanitic. If the percussion note becomes dull with a full inspiration, the test is positive².

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Special technique—tidal percussion

Simply have the patient breath in and out deeply while continuing to percuss. If the percussion note shifts from tympanic to dullness with a full inspiration, the test is positive-- splenomegaly more likely.

Interpretation

* Approximately 5% of normal adults have a palpable spleen tip (usually they are very thin).

* The finding of a palpable spleen increases greatly the probability of splenomegaly (+40%).

* The finding of a positive Castell’s sign increases modestly the probability of splenomegaly (+15%).

The examiner may miss an enlarged spleen by starting palpation too high in the abdomen.

3. Apply gel on a curve probe or a cardiac probe.

4. Put the probe on the Castell’s point with a transverse direction along the ICS.

5. Freeze the screen with a full inspiration.

6. Make an annotation “Y,” if positive sign.

Make an annotation “N,” if negative sign.

7. Save the image.

Spleen (visualized speen matches a positive sign) Bowel gas pattern

Reference

Bates’ guide to physical examination and history taking, 20^th edition, p479-480 Evidence-based physical diagnosis, 4^th edition, chapter 51, p438-440

Stanford 25: http://stanfordmedicine25.stanford.edu/the25/spleen.html Palpate the spleen: https://youtu.be/I5b2RaoB5Zk

Percuss the spleen: https://youtu.be/hhvGnBUNCgo Scan the spleen: https://youtu.be/uEBvNzwcw98

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Access the ascites

In patients with increased abdominal girth, a focused physical examination for ascites includes (1)

inspection for bulging flanks and leg edema, (2) percussion for flank dullness, (3) a test for shifting dullness, and (4) a test for a fluid wave. Two findings increase probability of ascites: a positive fluid wave and

presence of edema. Two finding decrease probability of ascites: flank tympany and absence of edema.

Techniques of Assessment Inspection: Bulging flanks

Inspection: Leg edema

Most patients with ascites also have edema, from hypoalbuminemia and the weight of the peritoneal fluid compressing the veins to the legs.

Percussion: Flank dullness

Examiner progressively percusses the abdomen beginning at the umbilicus moving toward the flanks, listening for the transition from tympany to dullness.Flank dullness is positive if there is a

horizontal border between dullness in the flank area and resonance (or tympany) in the periumbilical area.

Percussion: Shifting dullness

Examiner rolls the patient to the lateral recumbent position and repeats percussion. The area of

dullness shifts to the dependent side and the area of tympany shifts to the top. To be positive, the shifting border should remain horizontal.

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Percussion: Fluid waves

Ask the patient or an assistant to press the edges of both hands firmly down the midline of the

abdomen. This pressure helps to stop the

transmission wave through fat. While you tap one flank sharply with your fingertips, feel on the opposite flank for an impulse transmitted through the fluid. When ascites is present, an impulse may be felt in the receiving hand after a barely

perceptible lag.

Interpretation

* The finding of a fluid wave increases greatly the probability of ascites (+30%).

* The finding of a shifting dullness increases modestly the probability of ascites (+15%).

Most patients with ascites also have edema, from hypoalbuminemia and the weight of the peritoneal fluid compressing the veins to the legs. For cardic causes, you also have to check jugular vein pressure.

Reference

Bates’ guide to physical examination and history taking, 20^th edition, p484-485 Evidence-based physical diagnosis, 4^th edition, chapter 51, P.442-444

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3. Apply gel on a curvilinear probe.

4. Place the transducer over the patient’s right flank between mid-axillary and anterior axillary line with the transducer marker directed toward the patient’s head.

6. Make an annotation “Y,” if the student can find one of the five signs

Make an annotation “N,” if the student can not find any.

7. Save the image.

No free fluid Fluid in Morrison’s pouch

Video

https://youtu.be/uf4p6ZEalmU https://youtu.be/9EWJ-fbO4C8 https://youtu.be/5k6poKu19Yc

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Palpate the abdominal aorta

The purpose of palpation of the abdominal aorta is to look for abdominal aortic aneurysm (AAA).

There are no known risks associated with palpation of the abdominal aorta.

Steps and anatomy for detection of abdominal aortic aneurysm by palpation:

The clinician should place one hand on each side of the aorta and measure its diameter, subtracting the estimated thickness of two layers of skin and subcutaneous tissue:

1. The patient is supine, with his or her knees raised while the abdomen relaxes.

2. Positions both hands over the epigastrium with palms down, placing an index finger on either side.

3. Start palpation from bilateral mid-clavicular lines.

4. Move your left fingers toward midline until a transmitted pulse is considered present, then stop there.

5. Move your right fingers toward midline until a transmitted pulse is considered present, then stop there.

6. Measure the distance (A) between the index fingers.

7. Pinch the skin and subcutaneous tissue, and measure the skinfold thickness (S) over the epigastrium.

8. The aortic diameter is (A-S) cm.

Step 6 Step7

Interpretation

* A normal aorta is often readily palpable in thin patients or those with loose abdominal muscles.

* The aorta is normally less than 2.5 cm in diameter.

* An AAA was considered to be present when the aorta is judged to be 3.0 cm or greater. Sensitivity of palpation increases as AAAs enlarge: for widths of 3 to 3.9 cm, 29%; 4 to 4.9 cm, 50%; ≥5 cm, 76%.

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1. It is the width, and not the intensity, of the aortic pulsation that determines the diagnosis of an AAA.

2. The two most important variables governing whether an aneurysm is palpable are the size (≥5 cm )of the aneurysm and the girth ( < 100 cm) of the patient’s abdomen.

3. Apply gel on a curve probe or a cardiac probe.

4. The probe is placed transversely on the midsagittal line of the epigatrium.

5. Identify the aorta and measure the aora diameter outer wall to outer wall

7. Make an annotation: aorta diameter from PE Make an annotation “N,” if impalpable aorta.

8. Save the image.

Normal abdominal aorta (1.7cm) Abdominal aortic aneurysm (4cm)

Reference

Bates’ guide to physical examination and history taking, 20^th edition, p483 Evidence-based physical diagnosis, 4^th edition, chapter 51, p444

Palpate the abdominal aorta: https://youtu.be/npSyykd-lgA Scan the abdominal aorta: https://youtu.be/Ps4KuypceSk