Vital Signs/Chest Exam & Clinical Case Discussion

SMALL GROUP SESSION 13

December 2nd or December 4th

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)

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 year-old 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 102.7 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?

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 6th 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.
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.

ChestExamination Logistics:

Have your mentor demonstrate physical diagnosis of the chest, including:

Inspection: of normal movement of the chest, abdomen and adjacent (accessory) muscles during breathing
Palpation: of surface anatomy of the thorax: include clavicles, scapulae, spine, ribs, sternum, manubriosternal angle (angle of Louis) and xiphoid.
Palpation of the chest: expansion and tactile fremitus.
Percussion- technique; percussion of the diaphragms and diaphragmatic excursion.
Auscultation of the lungs: use of the stethoscope; normal breath sounds in various parts of the lung; posterior and anterior auscultation.
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 in the packet given to you at orientation 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?