I will next demonstrate the axillary exam to
look for lymph nodes. For purposes of this exam, I had Steve lower his gown, so you can easily see what it is that I'm doing
as I'm checking. I'll come over to
this side here, and I'll bring Steve's
arm up and I'll support his arm to allow relaxation
of the musculature, and I'll take my right hand, and I'll palpate along
the inside of the axilla. Coming up this way first, and then check blowing
the chest wall here. Then check along the
posterior musculature, just on the back
side of the axilla, and then along the anterior
musculature here as well. I've checked in this
area through here, through this area and
also through there. If you have a female patient and you don't remove the
gown, that's all right. You can either allow your arm or your hand to go
in under the sleeve here or from the back of the gown and checking
in the axillary region. Now I would do the same
thing on the other side. Again, lifting the patient's arm and either using the
same hand or the other, to again check in
the axillary region. Now I'll move to the
posterior thorax exam. Now, Neck, could you untie your gown and move
it off to the side of your back a little bit? For purposes of this video, I have Nick sitting on
the table sideways. As you're typically
examining patients, your patient will be sitting
forward on the table and you will move around
the patient as need be. Now the first part of the
posterior exam is inspection. Looking at the back,
checking for moles, checking the integrity
of the spine, how the spine lines
up in the middle. Now Nick can you take a
big breath and let it out, watching to see that
the chest expands and contracts normally
on both sides. Then I'll also palpate
as he is doing that. Nick can you take another
deep breath and let it out. That would be part
of the palpation of the thorax to make sure the lungs expand and
contract equally. Now the next part will
be to palpate the spine. I'll start at the very
top of the spine, palpating along the
spinous processes, and tell me if
there's any pain or tenderness as I'm
palpating here. Applying fairly firm pressure
enough so that I can see the whites of my fingers
beneath my fingernails. Then I'll do the
same thing along the muscles on either side
of the spine as well. Checking again for
any tenderness, any masses, or any
other abnormalities. I'll go all the way down
along the spine as well, following the edges
into the lumbar area. This is followed by percussion. With percussion,
you would percuss in at least four different
areas on the back, following a ladder like fashion, moving from one side and
then across to the other, percussing here, and then here. In a second area here, a third area here, and then a fourth area
here along the sides. Now, in a female patient, you have to make sure to cover the area of the chest underneath the axilla from the back
because you'll not be able to easily uncover that
in the anterior chest. Now, Nick, can you
cross your arms across your chest here
in front like this? What that does is that brings the scapula out to
the sides a little bit and allows you to percuss in these areas just
slightly easier. The next part of the exam is
auscultation of the lungs. Again, I'll follow
the same pattern with sceltation that I
did with percussion. Is the patient to take nice deep breaths with
his mouth open. And I'll listen to a
full inhalation and exhalation at each
of these locations. First, second area, third area. Again, under the axil. You can relax your arms, and you can move your
gown to the back again. Now I won't ask the patient
to tie his gown at this point because I'll be moving to
the anterior thorax exam. All right, Nick, if
you could turn around so that you're facing
towards the camera. Now, I'll proceed with
the anterior thorax exam. Could you lower
your gown so that it's sitting just
at your waist here. In a female patient, I
would ask her to lower a gown and hold this
up over her breast. But in a male patient,
it's perfectly acceptable to let the
gown sit at the waist. I have the patient here looking towards the camera for
purposes of this video. Normally, I would not
have the patient move. I'd have the patient
sitting forward with his feet resting
on the stool. I'll start again with inspection of the anterior chest here, looking again at the
skin for any moles, asymmetry from one side of the chest to
the other as well. I'll also then move into
percussion and I'll percuss at least four areas on each side of
the chest, again, following a ladder like pattern, upper part of the chest,
middle part of the chest, and lower part of the
chest here as well. In a female patient who's holding her gown
over her breast, I would percuss in about these
three areas on this side. Again, following the
ladder like distribution, across in those areas above her breast as she's holding the gown just above her breast. Then I'll follow this
with auscultation. Again, listening in three
areas of the chest, taking a deep breath here in and out with your mouth open, and again, continue that. And a third area here.
Okay. Thank you. Now you can replace your gown
up over your self there. That ends the
anterior thorax exam. Now I'm going to move on to
the cardiovascular exam. I'll start first with palpating
the carotid arteries. Carotid arteries
are best felt just laterally or just on the
outside of the trachea. First, I'll check
the right side. I'll let my hand sit there
for just a few pulse beats. Make sure I feel the pulse. Then I'll move over
to the left side, just on the outside of the
trachea again, papling. Notice I'm using several
fingers to find the pulse. Notice also that I'm checking one side and then the other. If Mary had arteriosclerosis or some thickening of the
wall of the arteries, and if I press both
sides at the same time, I may compromise the blood
supply to her brain. I'll check one side,
then the other. As I look at the neck, I see the sternocleidomastoid
muscles here on either side and the
trachea in the middle. And the carotid pulse is usually found right between
those two landmarks. After I find and palpate
the carotid pulse, then I'll take a listen
and listening to the carotid pulse and
all the other pulses for breweries is best accomplished
with use of the bell. What I'll do is I'll place the bell in the same place that I palpated the
carotid artery, and ask Mary, can you
hold your breath? I'll hold my breath
at the same time. I'll listen for a
few heartbeats. I'm listening for oohing
sounds that would indicate carotid breweries.
You can breathe again. Then I'll listen on
the left side again. Hold your breath again. All
right, and breathe again. Over the carotid arteries. You can sometimes hear the
sounds of S 1 and S 2, the heart sounds, but you shouldn't hear any extra
sounds in between that. That concludes looking
at the carotid arteries. Now I'll move on to the chest. Mary, could you lower your
gown a little bit further? The first part of
the examination of the heart is to
inspect the precordium. That means that I'll just
take a look at the chest, watch the chest rise and fall. Look for any extra pulse beats that would indicate an
enlargement of part of the heart. I also can notice
my landmarks here. Here's clavicle here on the right and
clavicle on the left. As I move to the center, there's a sternal notch at
the very top of the sternum, and I move down there's
the sternal angle. The sternal angle is
going to help us to locate the second
intercostal space. I find the sternal angle here. Then I move just laterally across from the sternal angle
to the right side. I'll locate the second
intercostal space. This is where I'll listen
to the aortic valve, and that is located between
the second and the third rib, the second intercostal
space here on this side, located just on the left side of the sternal angle also is the left, second
intercostal space, where I will listen to
the pulmonic valve. Now, what I'm going to do next, and for purposes
of demonstration, Mary's head is a little higher than what we
would typically have it. We want the bed to be at
about a 30 degree angle, but so the camera can better
see what we're doing. We have Mary at a
45 degree angle. So I've looked at the chest, I've inspected the precordium. Next, I'm going to
palpate the PMI. Mary, would you be able
to raise your gown there? And I'll hold the sheet
while Mary pulls the gown. There we go. All right. If you could pull your gown up just under your breast there. Now, the point of maximum
impulse is located right in the midclavicular line at about the fifth
intercostal space here. What I'm going to do to
palpate the PMI is place my whole hand just
beneath her left breast, and I'm going to
find a pulse there. When I find that with my hand, then I'll localize in
just with my fingertips. My fingertips. I want
to find where is it exactly located
and what is it size? As I'm pressing here, I'm feeling the pulse
right underneath, which is the point of
maximum impulse. All right. Now, I'm going to listen
to some heart valves, so you can lower your
gown again and bring the upper part
down just a little bit further if you
could. Same thing. Yeah. Mary has moved her
gown so that it's just above her breast so that I can start to listen
to the heart valves. I'll first listen to
the aortic valve. In the right second
intercostal space, allowing several
heartbeats to pass, listening to the quality
of S one and S two and for any murmurs in
between S one and S two. Then I'll move over to the
left second intercostal space. This is where I'll listen
to the pulmonic valve. Then tricuspid valve is located several intercostal spaces lower in about the fourth
intercostal space. Again, I'll listen for several heartbeats and make
sure I don't hear any differences in sounds or any sounds between
the valve sounds. Then I'll marry you can raise your gown again, bring
it up from below. The mitral valve is located in the fifth intercostal space right at the mid
clavicular line. Same place that you
find the PMI typically. I'll listen there also
with my I'm sorry, my diaphragm of my stethoscope. Again, listening to S 1 and S 2. Now located at the apex of the heart is
where you may hear some low pitched heart
murmurs and low pitched heart sounds that will work
with during PDS 3. These low pitched heart sounds are best heard with the bell, very similarly to the way
we heard carotid breweries. In the apex, you'll also listen not only
with the diaphragm, but also with the bell
of the stethoscope. Now, to use the bell correctly, you just very gently set
it on the chest wall. You're listening again for
any low pitched heart sounds. And that concludes the
cardiovascular exam.