Once I've listened
for bowel sounds, my next portion would be
to listen for breweries. Just like in other
parts of the exam, listening with the bell of the stethoscope is the best
way to listen for brewers. The aortic listening
fortic brewers is just above the umbilicus
in the center of the abdomen. Then moving up into the right
and left upper quadrants, just under the rib cage is where I would listen
for renal brewers. I again have my stethoscope in. Check, make sure
I'm using the bell. Listen just under the rib cage on the left upper quadrant. Again, letting several
beats of the heart pass, listening in the
right upper quadrant. Then again, listening
just above the umbilicus. The only sounds that I should
hear are bowel sounds, and occasionally, you can hear closure of the heart valves, but you should not hear
any extra sounds beyond that because those may
indicate abdominal breweries, which can go along
with atherosclerosis. Now, for the last part
of the abdominal exam, going to palpate the
abdominal aorta. This is fairly deep in the
center of the abdomen. What I will need to do is use
one hand to find the aorta. I'm going to press
fairly firmly. This might feel a
little uncomfortable because when you're
pressing on the aorta, it feels a little
uncomfortable to patients. I'm going to press
down deep until I feel that pulsation
very much like other pulsations that you
find where you need to press and apply
fairly good pressure. If find where the aorta is, I'll use both hands to
move to either side of either side of that particular pulsation and
find where the edges are, using my fingers to find the edges of the
aortic pulsation. Then I know the size of the aorta and the size
should be fairly small, two centimeters or
smaller in diameter. As I press my fingers on
either side of the aorta, I can get a rough estimate of whether that's normal
in size or not. That concludes the
abdominal exam. Now we'll move to the
upper extremity exam. The first thing with any
new part of the exam, course is to make
sure the patient is positioned properly, and for upper extremities, she should be sitting as we
have here, Mary is sitting. I want to see the whole arm. I'm going to roll
up Mary's sleeves. This is difficult for a patient to do herself.
I'll say, Mary. I'm just going to
roll your sleeves up here because I want to see the upper part of the arms as well as the lower
part of the arms. I'll do that on one side
and then on the other. With inspection, then I'm going to be looking at the arms, looking for symmetry,
always with skin, looking at any changes in moles or anything
that looks unusual. Look at hands, first
back of the hands, then Mary, could you
turn your hands over, and then the palms and looking up the fore
arms there where I'm seeing the inner aspect
of the arms as well. Next step, I'll
move on to pulses, and I'll start first
with brachial pulses, which you can have the patient make a little bit
of a muscle here. The biceps muscle can relax. Then you'll find the
brachial pulse just on the inner aspect of the brachial or the
biceps tendon here. Again, with any pulse, you have to leave your
fingers sit there for several heart beats in
order to feel the pulse. I want to compare that
to the other side. I'll make a little bit
of a muscle there. Good. I'll find the biceps
tendon on this side. Go just on the inner
aspect of that. To find a pulse, you have to press the artery
against something. In this case, I'm pressing it
against the biceps tendon. Normal pulses would
be two out of four, meaning that the pulse
is normal unexpected, four would be a bounding pulse, but this is what I expect and find here on her
brachial pulses. Then I'll compare radial pulses. Now I can check both radial
pulses at the same time. Again, I'm pressing
the radial artery against the bone underneath in order to feel the pulse here. I'm comparing sides, and again, two out of four being normal unexpected pulses in this case. Next part of the exam is
the lower extremities. We'll start this part
of the exam with the patient line down
and finish the exam, mostly the neurologic part of this with the patient
sitting upright. First, Mary, could you raise
your gown a little bit. The first part of this
as always is inspection. You can leave it down a
little. Yeah, that's fine. What I'll do first is look at
the legs, look at the feet, the toenails, look for
any hair distribution, any changes in any moles. Then I'll check for edema. What I'll do with
my hand is press fairly firmly on the
front of the tibia here, press hard enough so that I can see the whites of my nails here, and leaving my fingers there for at least a short period of time, releasing my fingers and then running my fingers
across that area where I is pressing to find out whether
there is any edema. Edema can be graded
on a scale from zero, no edema up to four plus. I'll check it again
then on the other side. Same thing, pressing
fairly firmly with my fingers so that I can
see the whites of my nails, leaving my fingers there for at least several
seconds and then releasing and moving my hand across the top here to find out whether
there's any edema. Following the exam of the lower extremities
looking for edema, the next part of this
is to check pulses. I'll start with femoral pulses, move to popliteal, then to dorsalis pedis, and posterior tibial pulses. So Mary, I'm going
to check a pulse that's in your groin
here, the femoral pulse. I wonder if you can
lower your shorts just about to the top
of your hips there. This is about where you'll
find the pulse here. And again, with any pulse, you need to press
fairly firmly against a solid structure in
order to find the pulse. With Mary Shorts lord here, I'm going to approach this
from the very top and press my fingers fairly deeply into the angle of
the groin here. Now, Mary, could you lower your shorts just a little bit more. Okay. Not quite down. That's good. Now, this is just about at the top of the pubic hair line is where I'm pressing. Again, it'll take
several pulse beats and I can feel a very
strong femoral pulse. If you can't feel
the femoral pulse, you're likely not
in the right place because this is
fairly easy to fine. I'll check first on the right. Then I'll use the
same technique, pressing just at about the
top of the pubic hair line, again, pressing fairly deeply. Allow my fingers to sit
there for a few moments. If I can't feel the
pulse readjusting my finger slightly
until I can find it. I can feel the pulse
very strong two out of four pulsation there on
the right left side also. Now I'm going to listen to each of the the femoral
arteries for breweries, just as what we did on the
neck and in the abdomen. Here we'll listen as well. I'll again use the bell of
my stethoscope and I'll allow the bell to sit in that same location where I
found the femeral pulse. Allowing several
heart beats to pass. I shouldn't hear anything. I may hear ball sounds, but no pulsating sounds. Then again, over
on the left side. The next pulse we'll check
is the popliteal pulse. The best way to do this is using all eight fingers of your hands, pressing into the popliteal
fossa and allowing your thumbs to stabilize your
fingers on the front here. What I'm doing is I'm
pressing fairly firmly in the popliteal fossa
until I feel a pulse, and it always takes
several heartbeats to pass in order to feel the pulse. Then I'm going to compare
that pulse to the other side. Again, lifting Mary's leg, letting her leg lie
against my fingers. And you can use your thumbs
to stabilize if you wish. Again, pressing until I
feel a good pulse there in the popliteal fossa and then comparing the right and the left that they
feel about the same. Next, I'll move to
the foot pulses. The first one to check is the
dorsalis pedis pulse here. The dorsalis pedis pulse
is best identified by artificially drawing
a triangle from the first and second
toe up to a point here, and you'll find the pulse typically right in
that region there. You don't always find it
there and may need to readjust your fingers
into another area, but if you start there, that's a fairly good place to start. Then I'll compare that pulse
over to the left side, where again, I'll artificially
draw a triangle there. Place my fingers in that area. You notice I'm using
several fingers because I'm more likely to find it if I'm pressing with
several fingers, and if I wanted to
then localize into where I feel the pulse with
one digit, I can do that. Pulses, of course, are
graded on a scale 0-4, where two is the expected
pulse that you'd find. The next pulse to check,
and on the right leg, I'll check the
posterior tibialis located behind the
medial malleolus. You notice I have my
fingers wrapped just behind the medial
malleolus here. Again, pressing
the artery against the malleolus until I feel
a very good pulse there. Then comparing again on the
other side, same thing, wrapping my fingers just around the back of
the medial malleolus, and pressing fairly firmly there until I feel
a pulse again.