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31 - Examination of the heart and great vessels
- from Section 7 - Heart and thorax
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- By Martin T. Yates, Cardiothoracic Surgery, St George's Hospital, London, UK, Petrut Gogalniceanu, Spiridon University Hospital, Ian Hunt, St George's Hospital, London, UK
- Edited by Petrut Gogalniceanu, James Pegrum, William Lynn
-
- Book:
- Physical Examination for Surgeons
- Published online:
- 05 July 2015
- Print publication:
- 25 June 2015, pp 264-270
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Summary
Checklist
WIPER
• Patient sitting on edge of examination couch with all clothing above the waist removed
Physiological parameters
General
• Bedside: GTN spray, cigarettes, oxygen
• Cachexia: severe mitral valve disease
• Morbidly obese: cor pulmonale
Inspection
• Hands: nicotine stains, radial artery harvest
• Neck: JVP
• Chest wall : scars of previous chest surgery (midline, lateral and posterior)
• Legs: groin incisions, varicose veins, scars from vein harvest
Palpation
• Hands: radial artery pulse: rate and rhythm
• Neck: carotid pulse, pulsatile trachea (aortic arch aneurysm), carotid–carotid or carotid–subclavian bypass, visible JVP
• Chest wall: apex beat, heaves, thrills, pacemaker, implantable defibrillator
• Sacrum: sacral oedema
• Legs : peripheral oedema, radio-femoral delay
Auscultation
• Carotid artery: bruit
• Precordium: heart sounds, murmurs, pericardial rub
• Lung bases: effusion, pulmonary oedema
To complete the examination…
• Chest x-ray
• ECG
Examination notes
What are the basic cardiac symptoms?
The main symptoms of cardiac disease are chest pain, shortness of breath, ankle swelling, orthopnoea, paroxysmal nocturnal dyspnoea, palpitations and syncope.
How do you prepare for the examination of the cardiac surgery patient?
The patient needs to be lying at 45° in underwear on the examination couch. The groins are covered but the legs are exposed.
What do you inspect in the examination of the heart?
• Jugular venous pressure (JVP). The patient is positioned at 45° with the head slightly turned to the contralateral side. Look for the JVP wave form and the height above the sternal notch. It should normally be seen 3 cm vertically above the sternal angle. A raised JVP is associated with congestive cardiac failure, pericardial tamponade or constrictive pericarditis. A collapsed JVP is caused by dehydration or shock.
• Identify scars from previous carotid endarterectomy.
• Inspect the chest for scars from previous cardiac or thoracic surgery.
• Inspect the legs for scars from previous saphenous vein harvest or varicose vein avulsions.
• The groins must be checked for evidence of previous vascular or endovascular surgery or percutaneous intervention.
• At the beginning or end of the examination the patient should be asked to stand, to look for varicose veins.
30 - Examination of the thorax and lungs
- from Section 7 - Heart and thorax
-
- By Martin T. Yates, St George's Hospital, Petrut Gogalniceanu, London Postgraduate School of Surgery, Ian Hunt, St George's Hospital
- Edited by Petrut Gogalniceanu, James Pegrum, William Lynn
-
- Book:
- Physical Examination for Surgeons
- Published online:
- 05 July 2015
- Print publication:
- 25 June 2015, pp 255-263
-
- Chapter
- Export citation
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Summary
Checklist
WIPER
• Patient sitting on edge of examination couch with all clothing above the waist removed
Physiological parameters
General
• End of bed: shortness of breath, wheeze
• Bedside: sputum pot, bedside oxygen, cigarettes, inhalers
• Hands: nicotine staining and finger clubbing
• Face: Horner's syndrome (ptosis and meiosis) and venous engorgement of head and neck veins
Inspection
• Neck: lymphadenopathy, low transverse cervical scar for mediastinoscopy, tracheostomy scar, tuberculous abscesses
• Chest wall deformities: pectus excavatum (pushed in) or pectus carinatum (pushed out)
• Chest movement: asymmetry of expansion, contraction of one side of the chest wall, paradoxical movement (flail chest)
• Scars: midline sternotomy, lateral/posterior/posterolateral thoracotomy, small scars (video-assisted thorascopic surgery or chest drains)
• Radiotherapy tattoos
• Chest drains
Palpation
• Neck: lymphadenopathy, goitre, position of trachea
• Chest: sternal tenderness or instability, rib tenderness, asymmetry of expansion
Percussion
• Chest wall: resonant, dull or hyper-resonant
Auscultation
• Chest wall: breath sounds (vesicular, crackles, wheeze, reduced air entry)
To complete the examination…
• Bedside spirometry
• Chest x-ray
Examination notes
What are the basic thoracic and pulmonary symptoms?
The main symptoms of thoracic disease are shortness of breath, fatigue, wheeze, stridor, cough, sputum production, haemoptysis, chest pain and voice hoarseness.
How do you prepare for the examination of the thorax?
The patient needs to be sitting on the edge of the examination couch, exposed from the waist up.
What do you look for during inspection?
• Start the examination by inspecting the hands. Look for nicotine stains from cigarette smoking (risk factor for lung malignancy) and finger clubbing (a possible sign of malignancy or chronic lung disease).
• Move up to the face, looking at the eyes for evidence of ptosis (drooping of the eyelid) and meiosis (a constricted pupil), which are signs of Horner's syndrome. This may be caused by a Pancoast's tumour originating from the superior sulcus of the lung.
10 - Musical contexts II: characterisation and emotion in the Savoy operas
- from Part II - Focus
- Edited by David Eden, Meinhard Saremba
-
- Book:
- The Cambridge Companion to Gilbert and Sullivan
- Published online:
- 28 September 2011
- Print publication:
- 06 August 2009, pp 136-150
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Summary
A proper understanding of Sullivan's creative stance is central to any discussion of the musical contribution to the Savoy operas. During the course of an interview given to the San Francisco Daily Chronicle in 1885 he made what amounts to a ‘mission statement’ regarding his approach to composition for the stage. ‘I adhere’, he said, ‘to the principles of art which I had learned in the production of more solid works, and no musician who analyses the score of those light operas will fail to find the evidence of seriousness and solidity pointed out’.
The use of the word ‘serious’ does not mean that Sullivan wished his music to be sombre and sad, but that it should be responsive to any stimulus, whether comic or serious – he certainly did not see emotional seriousness as the antithesis of comedy. In addition a central part of his stated seriousness of purpose emerges as a belief in real emotion, which for him was intuitively linked to a sense of humanity. Expressing scepticism towards Italian, French and Wagnerian opera, he rejected the maxim that opera is of life, but larger than it. Rather he was inclined to make emotion not ‘unreal and artificial’ as he put it, but as real as possible – a natural reaction to credible experience. Time after time he ensures that his musical settings remain sympathetic to the characters themselves, giving them a degree of dignity even while embracing their sometimes unpleasant Gilbertian features.
Looking Backward, Looking Forward: MLA Members Speak
- April Alliston, Elizabeth Ammons, Jean Arnold, Nina Baym, Sandra L. Beckett, Peter G. Beidler, Roger A. Berger, Sandra Bermann, J.J. Wilson, Troy Boone, Alison Booth, Wayne C. Booth, James Phelan, Marie Borroff, Ihab Hassan, Ulrich Weisstein, Zack Bowen, Jill Campbell, Dan Campion, Jay Caplan, Maurice Charney, Beverly Lyon Clark, Robert A. Colby, Thomas C. Coleman III, Nicole Cooley, Richard Dellamora, Morris Dickstein, Terrell Dixon, Emory Elliott, Caryl Emerson, Ann W. Engar, Lars Engle, Kai Hammermeister, N. N. Feltes, Mary Anne Ferguson, Annie Finch, Shelley Fisher Fishkin, Jerry Aline Flieger, Norman Friedman, Rosemarie Garland-Thomson, Sandra M. Gilbert, Laurie Grobman, George Guida, Liselotte Gumpel, R. K. Gupta, Florence Howe, Cathy L. Jrade, Richard A. Kaye, Calhoun Winton, Murray Krieger, Robert Langbaum, Richard A. Lanham, Marilee Lindemann, Paul Michael Lützeler, Thomas J. Lynn, Juliet Flower MacCannell, Michelle A. Massé, Irving Massey, Georges May, Christian W. Hallstein, Gita May, Lucy McDiarmid, Ellen Messer-Davidow, Koritha Mitchell, Robin Smiles, Kenyatta Albeny, George Monteiro, Joel Myerson, Alan Nadel, Ashton Nichols, Jeffrey Nishimura, Neal Oxenhandler, David Palumbo-Liu, Vincent P. Pecora, David Porter, Nancy Potter, Ronald C. Rosbottom, Elias L. Rivers, Gerhard F. Strasser, J. L. Styan, Marianna De Marco Torgovnick, Gary Totten, David van Leer, Asha Varadharajan, Orrin N. C. Wang, Sharon Willis, Louise E. Wright, Donald A. Yates, Takayuki Yokota-Murakami, Richard E. Zeikowitz, Angelika Bammer, Dale Bauer, Karl Beckson, Betsy A. Bowen, Stacey Donohue, Sheila Emerson, Gwendolyn Audrey Foster, Jay L. Halio, Karl Kroeber, Terence Hawkes, William B. Hunter, Mary Jambus, Willard F. King, Nancy K. Miller, Jody Norton, Ann Pellegrini, S. P. Rosenbaum, Lorie Roth, Robert Scholes, Joanne Shattock, Rosemary T. VanArsdel, Alfred Bendixen, Alarma Kathleen Brown, Michael J. Kiskis, Debra A. Castillo, Rey Chow, John F. Crossen, Robert F. Fleissner, Regenia Gagnier, Nicholas Howe, M. Thomas Inge, Frank Mehring, Hyungji Park, Jahan Ramazani, Kenneth M. Roemer, Deborah D. Rogers, A. LaVonne Brown Ruoff, Regina M. Schwartz, John T. Shawcross, Brenda R. Silver, Andrew von Hendy, Virginia Wright Wexman, Britta Zangen, A. Owen Aldridge, Paula R. Backscheider, Roland Bartel, E. M. Forster, Milton Birnbaum, Jonathan Bishop, Crystal Downing, Frank H. Ellis, Roberto Forns-Broggi, James R. Giles, Mary E. Giles, Susan Blair Green, Madelyn Gutwirth, Constance B. Hieatt, Titi Adepitan, Edgar C. Knowlton, Jr., Emanuel Mussman, Sally Todd Nelson, Robert O. Preyer, David Diego Rodriguez, Guy Stern, James Thorpe, Robert J. Wilson, Rebecca S. Beal, Joyce Simutis, Betsy Bowden, Sara Cooper, Wheeler Winston Dixon, Tarek el Ariss, Richard Jewell, John W. Kronik, Wendy Martin, Stuart Y. McDougal, Hugo Méndez-Ramírez, Ivy Schweitzer, Armand E. Singer, G. Thomas Tanselle, Tom Bishop, Mary Ann Caws, Marcel Gutwirth, Christophe Ippolito, Lawrence D. Kritzman, James Longenbach, Tim McCracken, Wolfe S. Molitor, Diane Quantic, Gregory Rabassa, Ellen M. Tsagaris, Anthony C. Yu, Betty Jean Craige, Wendell V. Harris, J. Hillis Miller, Jesse G. Swan, Helene Zimmer-Loew, Peter Berek, James Chandler, Hanna K. Charney, Philip Cohen, Judith Fetterley, Herbert Lindenberger, Julia Reinhard Lupton, Maximillian E. Novak, Richard Ohmann, Marjorie Perloff, Mark Reynolds, James Sledd, Harriet Turner, Marie Umeh, Flavia Aloya, Regina Barreca, Konrad Bieber, Ellis Hanson, William J. Hyde, Holly A. Laird, David Leverenz, Allen Michie, J. Wesley Miller, Marvin Rosenberg, Daniel R. Schwarz, Elizabeth Welt Trahan, Jean Fagan Yellin
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- Journal:
- PMLA / Publications of the Modern Language Association of America / Volume 115 / Issue 7 / December 2000
- Published online by Cambridge University Press:
- 23 October 2020, pp. 1986-2078
- Print publication:
- December 2000
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