SMALL GROUP SESSION 13 December 1 st or December 3 rd

Transcription

1 SMALL GROUP SESSION 13 December 1 st or December 3 rd Vital Signs/Chest Exam & Clinical Case Discussion Suggested Readings: Complete online physical examination module and quiz. Review Mosby s Guide to Physical Examination: Chapter 13 Chest & Lungs Prepare by: Dressing for the chest exam workshop (two piece outfit, sports bra). Bring: Physical examination equipment (stethoscopes and blood pressure cuff). Mentors: Bring physical exam supplies (mats, gowns, handwashing gel) Bring a physical diagnosis text. OSCE sheets for this session. Brief outline: Section 1: Touch base (15 minutes) Section 2: Clinical Case Discussion A 36 year-old woman with cough and fever(80 minutes) Section 3: Vital signs and chest exam (80 minutes) Section 4: Evaluate Session (5 minutes) 1

2 Objectives for Session 13: By the end of this session students will be able to: Develop an approach to analyzing a clinical case with cough symptoms Apply knowledge of chest anatomy to the clinical discussion Practice taking accurate blood pressures Practice performing chest examination Section 1: Touch base (15 minutes) Your SP video interviews are scheduled over the next two weeks. Discuss any questions or concerns you may have with the group. Section 2: Clinical Case Discussion (80 minutes) A 36 year-old woman with cough and fever Case Part 1: You are a primary care physician, and your last patient of the day is Ms. R, a 36 yearold third grade teacher who called earlier complaining of a annoying painful cough. She has been a patient in your practice for several years, but she has only come in for routine health maintenance visits, so you do not immediately recognize her name. She says that she has had an annoying dry (non-productive) cough for two or three days, and that this morning she started feeling sick all over. After measuring her temperature at F at home, she called in sick to work. Past Medical History: Ms. R reports being very healthy most of her life. Her only hospitalizations were for an appendectomy at age 12, and for the birth of her sons, ages 5 and 8, which she reports as uncomplicated deliveries. A review of her chart shows that she has kept up with routine Pap smears and pelvic exams, and has had one routine mammogram which was normal. She is on no medications. Social History: She does not smoke, drinks one to two glasses of wine one or two times weekly. She is a third grade teacher at a local elementary school, and is married with two young sons. What are your thoughts at this point? Are there other things you want to ask about? 2

3 Case Part 2 Vital signs: T 102.5F, R 20, P 100, BP 128/75. As she talks, you notice that Ms. R sits forward slightly in her chair, and is obviously uncomfortable, especially at the ends of sentences as she takes a deep breath. Anterior and posterior appearance of the chest is unremarkable, but as you place your stethoscope over the left mid-scapular line at the level of the 6 th thoracic vertebrae, Ms. R winces with pain and stiffens her posture. Pain to palpation is relatively localized to this area, but she reports pain with inspiration over the entire left side of her chest. Breath sounds are decreased on the left as compared to the right, particularly in the lower half of the left lung field. She continues to sit very stiffly and shifts several times in her chair during the examination. The remainder of her physical exam is unremarkable. Which anatomical structures might be involved in her complaints of pain with coughing and the tenderness on palpation? Where do the physical exam findings lead you in your thinking about the cause of her complaints? What role does the finding of fever play in developing your differential? What x-rays or other tests might be helpful in evaluating these complaints? As you are completing your exam and filling out an x-ray request, Ms. R steps down from the exam table to the floor, saying, Sorry I need to stand for a minute I slipped and fell on the metal bleachers at my son s soccer game last Saturday. My back and tailbone have been sore ever since. What could explain the patient s complaints and exam findings? For further information, the following link may be helpful: Section 3: Vital Signs and Chest Exam (80 minutes) Overview of blood pressure measurement Check to be sure patient has not had an arteriovenous fistula or mastectomy: blood pressure measurement is contra-indicated ipsilateral to these conditions. Select an appropriately sized blood pressure cuff. Place the cuff snugly about the patient s arm, with the center of the bladder over the brachial artery, and the cuff 2 to 3 cm above the antecubital fossa. Support the patient s arm near heart level. Palpate the radial pulse. Pump up the cuff until you cannot feel the radial pulse, and then pump it up an additional 20 mm of Hg. 3

4 Deflate the cuff at a rate of 2 to 3 mm Hg per minute and note the pressure when the radial pulse is palpable- the palpable systolic pressure, then deflate the cuff rapidly. Wait 30 seconds, and then pump up the cuff to 20 mm Hg over the palpable systolic pressure. While listening with the bell of your stethoscope over the antecubital fossa, release the pressure from the cuff at a rate of 2 to 3 mm Hg per minute. Note the pressure at which the first two consecutive beats heard (phase I of Korotkoff sounds) - the systolic blood pressure. Note the last beat heard (phase V of Korotkoff sounds). Deflate the cuff immediately. Record phase I of Korotkoff sounds as systolic blood pressure, and phase V of Korotkoff sounds as diastolic blood pressure. The blood pressure should be repeated in the other arm, if this is the first time you have measured the patient s blood pressure. Chest Examination Logistics: Have your mentor demonstrate physical diagnosis of the chest, including: 1. Inspection: of normal movement of the chest, abdomen and adjacent (accessory) muscles during breathing 2. Palpation: of surface anatomy of the thorax: include clavicles, scapulae, spine, ribs, sternum, manubriosternal angle (angle of Louis) and xiphoid. 3. Palpation of the chest: expansion and tactile fremitus. 4. Percussion- technique; percussion of the diaphragms and diaphragmatic excursion. 5. Auscultation of the lungs: use of the stethoscope; normal breath sounds in various parts of the lung; posterior and anterior auscultation. 6. Vocal resonance while auscultating with the stethoscope, ask patient to say ee. After this, break into pairs again and practice examining each other. For this session, we suggest you go into two separate same-gender rooms. Your physician mentor should go from one room to another to answer questions and demonstrate technique. OSCE sheets for this session are at the end of this session and are also available on the POM-1 website. Section 4: Evaluate Session (5 minutes) How did this session go? Did you have enough time for each section? 4

5 Vital Signs A = Attempted Satisfactory B = Attempted Below Satisfactory C = Did Not Attempt Procedure A B C Comments 1. BP: Ex should slightly flex patients arm, and support arm (table, hold arm, etc). 2. BP: Ex should check size of cuff, locate brachial artery by palpation, and place cuff snugly about upper arm, centering the bladder over the brachial artery arm should be free of clothing. 2. BP: Ex should palpate radial pulse, and pump up blood pressure cuff until radial pulse is no longer palpable, and then rapidly deflate the cuff, and wait 30 seconds before proceeding Ex should place stethoscope (bell preferred, diaphragm acceptable) over brachial artery, and pump up cuff 20 to 30 mm Hg above palpable systolic pressure, and then release cuff slowly, at rate of 2 3 mm Hg per second, listening for Korotkoff sounds. Ex should record blood pressure. 4. PULSE: Ex should palpate the radial artery for at least 15 seconds. 5. RESPIRATION: Ex should stand in front or behind you and observe your breathing at rest for at least 30 seconds (normal rate is breaths per minute). ASK Ex what your respiratory rate was during the feedback session. 5

6 Chest and Lung A = Attempted Satisfactory B = Attempted Below Satisfactory C = Did Not Attempt Procedure A B C Comments 1. INSPECTION OF CHEST: Ex should visually inspect Pt s chest while sitting for shape and symmetry, symmetry of respiratory excursion, pulsations, heaving and respiratory effort. (Ex should state what they are inspecting for) 2. THORACIC EXPANSION: While standing behind Pt, Ex should place thumbs parallel and several inches lateral to his/her mid to lower spine. Pt should then be asked to inhale deeply while Ex feels the range and symmetry of Pt s respirations. 3. TACTILE FREMITUS: While standing behind Pt, Ex should place his/her palmar or ulnar surface of both hands on Pt s upper, middle, and lower back. Ex should ask Pt to recite a few words or numbers (ex. 99 ) while he/she palpates with a firm, light touch both sides simultaneously. 4. PERCUSSION: Ex percusses over posterior and anterior chest. Ex should move from one side across to the other and down PERCUSSION TECHNIQUE: Ex places middle finger, which is hyperextended, against your skin, lifting the rest of the stationary hand up. Using the middle finger of the dominant hand, Ex should bounce it off the stationary one. 5. DIAPHRAGMATIC EXCURSION: Ex should ask Pt to take a deep breath and hold it while Ex percusses down the scapular line of spine. Ex should then ask Pt to exhale and hold it as much as possible while he/she percusses the back. Both inhale and exhale percussion procedures should be done on both sides of the Pt s back. 6. POSTERIOR BREATH SOUNDS: Ex should ask Pt to breathe deeply through mouth while Ex listens to AT LEAST ONE FULL BREATH AT EACH POSITION on the back. Ex should move from one side of the back across to the other and down. 7. ANTERIOR BREATH SOUNDS: Ex should use stethoscope to listen to both sides of the front of Pt s chest. Ex should progress from side to side moving downward using the same sequence while listening to one full respiration on each location. 8. AUSCULTATION TECHNIQUE: Ex should listen to the Pt s chest using the diaphragm of the stethoscope, which should be pressed firmly onto chest. 9. VOCAL RESONANCE: While auscultating with the stethoscope over the back, the examiner asks the patient to say.e-e-e The examiner should move the stethoscope from one side to the other, moving downward, while listening to patient say e-e-e at each location. 6

7 7

8 8