Physical Exam Chest
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- Pages: 43
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Physical Examination: Thorax
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
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Thorax ■
Heart
■
Lungs
■
Inspect, palpate, percuss, auscultate
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Anterior Chest Landmarks
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
■
Anterior: Midsternal, midclavicular, anterior axillary
■
To identify the 2 ICS: Palpate the clavicle and follow it to the sternum; note the suprasternal notch. Follow the sternum down and palpate the bony ridge (manubrium); move finger laterally to find the 2nd rib. (The 2nd rib is the first one felt since the 1st rib is beneath the clavicle). The 2nd ICS is the space beneath the 2nd rib.
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Posterior Chest Landmarks ■
anteroposterior diameter compared with transverse (NV 1:2)- AP diameter is < transverse. A barrel chest is associated with pulmonary emphysema or normal aging.
■
Note any retraction of the interspaces during inspiration- found in emphysema, tracheal or laryngeal obstruction. Seen in newborns.
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
■
Percussion- adv. work. Range: resonance (hollow); hyper resonance (booming); dullness (masses, fluid
■
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Anterior Thorax
■
.Inspect/ count respiratory rate (15-20/min) and note rhythm. Note respiratory effort; use of neck muscles or abdominal breathing. Observe intercostals spaces for retraction (obstruction) or bulging (emphysema).
■
Palpation- may palpate for masses or crackling feeling (cepitussubcutaneous air).
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Lateral Chest Landmarks
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Inspection ■
Lesions
■
Chest excursion
■
Pattern of breathing
■
Obvious lesions
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Palpation ■
Tender areas
■
Nodules
■
Fremitus
■
Chest excursion
■
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
1.
Tactile Fremitus: Normal lung transmits a palpable vibratory sensation to the chest wall. This is referred to as fremitus and can be detected by placing the ulnar aspects of both hands firmly against either side of the chest while the patient says the words "Ninety-Nine." This maneuver is repeated until the entire posterior thorax is covered. The bony aspects of the hands are used as they are particularly sensitive for detecting these vibrations.
■ Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
listening for breath sounds: posterior
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
listening for breath sounds: lateral
Copyright © 2000 by W. B. Saunders Company. All rights reserved. p. 196.
MENU
back
listening for breath sounds: lateral ■
Copyright © 2000 by W. B. Saunders Company. All rights reserved. p. 196.
MENU
back
listening for breath sounds: anterior
Copyright © 2000 by W. B. Saunders Company. All rights reserved. p. 196.
MENU
back
Normal percussion notes: anterior
Copyright © 2000 by W. B. Saunders Company. All rights reserved. p. 198.
MENU
back
Normal percussion notes: posterior
Copyright © 2000 by W. B. Saunders Company. All rights reserved. p. 198.
MENU
back
Auscultation ■
■
■
breath sounds occur as a result of the movement of air through the theright trachea, ■ Visualize bronchi and alveoli. lung is divided into 3 lobes, the left, into Use diaphragm; have client breath two. Apex is at the through mouth, more deeply than usual. top; base at the bottom. Sounds are assessed side-toside; anterior and posterior. Copyright © 2000 Copyright by W. B.©Saunders 2000 by W. Company. B. Saunders All rights Company. reserved. All rights reserved.
The middle lobe is best assessed on the right side under the arm
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Normal breath sounds: Vesicular ■
; soft, low, heard in periphery and base of lungs.
soft, low, heard in periphery and base of lungs.
■
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Normal breath sounds: bronchovesicular ■
medium pitch, heard between scapula and anteriorly close to sternum.
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Normal breath sounds: bronchial ■
loud and harsh; heard over trachea. Abnormal when heard elsewhere (pneumonia, tumor).
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Abnormal breath sounds ■
Adventitious (abnormal) breath sounds occur when air passes through narrowed airways filled with fluid or mucus; superimposed over normal breath sounds.
■
Crackles, fine rales fine, high pitched crackling sound;
■
Rhonchi, course- low pitched, gurgling; moaning, snoring quality, clear with coughing Wheezes, high pitched, squeaky inspiratory, expiratory
■
http://depts.washington.edu/~physdx/pulmonary/tec h.html
■
http://www.med.ucla.edu/wilkes/lungintro.htm Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Assessment sites for the assessment of the precordium
Copyright © 2000 by W. B. Saunders Company. All rights reserved. p. 200.
MENU
back
■
Heart lies behind and to the left of the sternum. The upper portion or atria (BASE) lies to the back; the ventricles (APEX) points forward, the apex of the left ventricle actually touches the anterior chest wall near the left midclavicular line at or near the 5th left ICS. Known as point of maximal impulse (PMI) and is where apical beat is assessed. Impulse is a good index of heart size.
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
■
Known as point of maximal impulse (PMI) and is where apical beat is assessed. Impulse is a good index of heart size.
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
■
Aortic area- 2nd ICS to right of sternum (closure of the aortic valve loudest here).
■
Pulmonic area- 2nd ICS to left of sternum (closure of the pulmonic valve loudest here).
■
Tricuspid- 5th ICS left of sternal border (closure of tricuspid valve).
■
Mitral- 5th ICS left of the sternum just medial to MCL (closure of mitral valve).
■
http://medicine.ucsd.edu/c linicalmed/heart.htm
Copyright © 2000 by W. B. Saunders Company. All rights reserved. ■
back
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
■
Inspection- look for lift at apex.
■
Auscultation- Client should be assessed in supine position with head up to 45 deg.; examiner stands at right side. Use diaphragm for basic sounds; bell for murmurs and extra sounds.
■
Identify the heart rate, rhythm; bell for murmurs aortic, pulmonic, mitral
■ Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Auscultating Heart Sounds ■
http://www-medlib.med.utah.edu/kw/pharm/hyper_heart1.html
■
Blood flows from R. atrium to R. ventricle through the atrioventricular valve, the tricuspid. Blood flows from L. atrium to L. ventricle through the mitral valve. Blood passes from R. ventricle to pulmonary artery through the pulmonic valve and from the left ventricle to aorta through the aortic valve (semilunar valves). Events on the left side of the heart slightly precede those on the right.
■
http://www.austincc.edu/adnlev1/rnsgskills2online/physical_assessment_b/MVPNor mal.gif
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
MENU
back
Auscultating Heart Sounds ■
■
S1 produced by closure of the atrioventricular valves, mitral and tricuspid)- loudest at mitral area. The sound is a dull, low pitched “lub.” S2 (produced by closure of aortic and pulmonic valve) is higher pitched, shorter and is the “dub” sound. Heard best at the base (aortic and pulmonic areas). S-2 is normally louder than S-1
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
MENU
back
Auscultating Heart Sounds – S3 rapid filling of the ventricle with blood; heard following S-2. Can be normal in young adults and children; pathologic in elderly – S4 atrial contraction and thought to result from stiffened left ventricle; directly precedes S-1. Heard in elderly.
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
MENU
back
Auscultating Heart Sounds ■
Extra Heart Sounds snaps and clicks refer to valves: aortic and mitral stenosis, prosthetic valve – Murmurs: swishing or blowing sounds caused by o Forward flow through a steno tic valve o Increased flow through a normal valve o Backward flow through a valve that fails to close.
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
MENU
■
http://egeneralmedical.com/listohearmur.html http://depts.washington.edu/~physdx/heart/demo.html
■
to listen to sounds http://www.med.ucla.edu/wilkes/Physiology.htm
back
Cardiac Cycle
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Evaluating Heart Murmurs ■
Intensity
Peripheral Vascular Graded on a scale of 1 to 6System: Grade assessment I (barely audible) to Grade VI (loud and may be heard of BP, palpation of without the stethoscope). peripheral puses, inexpection of jugular Pattern quality and peripheral vessels and inspection of skin Location tissues to determine Radiation perfusion to the extremities. ■
■
■ ■ ■ ■
Posture
■ Copyright © 2000 by W. B. Saunders Company. All rights reserved.
MENU
back
■
Inspect neck for pulsations and jugular veins for distention. JVD refers to jugular venous distentionindex of function of the right atrium.
■
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
■
Advanced practitioners would ausculate the carotid artery for a bruit (blowing or swishing sound) and palpate a thrill (a vibrating sensation).
■ Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Inspect and palpate skin of hands, feet and legs ■
for color, temperature and edema. Unilateral coolness may be associated with decreased blood flow and should be correlated with pulse in that extremity.
■
Arterial insufficiency- cool extremity, dec. or absent pulse, color changes.
■
Venous insufficiency- normal temperature, normal pulses, color changes; skin changes. Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Inspect and palpate skin of hands, feet and legs ■
Deep vein thrombosis (DVT)- Homan’s sign: Knee flexed- pain in calf with dorsiflexion of foot. Not performed if pt. is dx’d with thrombus.
■
Edema- fluid accumulation in the tissues; assess by pressing firmly with the thumbusually over shin or medial maleolus of foot. Graded on scale of 1+ - 4+.
■ Copyright © 2000 by W. B. Saunders Company. All rights reserved.
1
Physical Examination: Thorax
2
Thorax
3
Anterior Chest Landmarks
4
"Anterior"
5
Posterior Chest Landmarks
6
"Palpate – respiratory excursion"
7
"Percussion- adv"
8
Anterior Thorax
9
Lateral Chest Landmarks
10
Inspection
11
Palpation
12
"Tactile Fremitus"
13
listening for breath sounds: posterior
14
listening for breath sounds: lateral
15
listening for breath sounds: lateral
16
listening for breath sounds: anterior
17
Normal percussion notes: anterior
18
Normal percussion notes: posterior
19
Auscultation
20
"Visualize the right lung is..."
21
"The middle lobe is best..."
22 23
Auscultation
24
Normal breath sounds: Vesicular
25
Normal breath sounds: bronchovesicular
26
Normal breath sounds: bronchial
27
Abnormal breath sounds
28 29
Assessment sites for the assessment of the precordium
30
"Heart lies behind and to..."
31
"Known as point of maximal..."
32
"Aortic area- 2nd ICS to..."
33 34
"Inspection- look for lift at..."
35
Auscultating Heart Sounds
36
Auscultating Heart Sounds
37
Auscultating Heart Sounds
38
Auscultating Heart Sounds
39
Places to listen to sounds
40
Cardiac Cycle
41
Evaluating Heart Murmurs
42
"Peripheral Vascular System"
43
"Inspect neck for pulsations and..."
44
"Advanced practitioners would ausculate the..."
45
Inspect and palpate skin of hands, feet and legs
46
Inspect and palpate skin of hands, feet and legs
47
THE END
Physical Examination: Thorax
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Thorax ■
Heart
■
Lungs
■
Inspect, palpate, percuss, auscultate
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Anterior Chest Landmarks
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
■
Anterior: Midsternal, midclavicular, anterior axillary
■
To identify the 2 ICS: Palpate the clavicle and follow it to the sternum; note the suprasternal notch. Follow the sternum down and palpate the bony ridge (manubrium); move finger laterally to find the 2nd rib. (The 2nd rib is the first one felt since the 1st rib is beneath the clavicle). The 2nd ICS is the space beneath the 2nd rib.
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Posterior Chest Landmarks ■
anteroposterior diameter compared with transverse (NV 1:2)- AP diameter is < transverse. A barrel chest is associated with pulmonary emphysema or normal aging.
■
Note any retraction of the interspaces during inspiration- found in emphysema, tracheal or laryngeal obstruction. Seen in newborns.
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
■
Percussion- adv. work. Range: resonance (hollow); hyper resonance (booming); dullness (masses, fluid
■
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Anterior Thorax
■
.Inspect/ count respiratory rate (15-20/min) and note rhythm. Note respiratory effort; use of neck muscles or abdominal breathing. Observe intercostals spaces for retraction (obstruction) or bulging (emphysema).
■
Palpation- may palpate for masses or crackling feeling (cepitussubcutaneous air).
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Lateral Chest Landmarks
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Inspection ■
Lesions
■
Chest excursion
■
Pattern of breathing
■
Obvious lesions
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Palpation ■
Tender areas
■
Nodules
■
Fremitus
■
Chest excursion
■
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
1.
Tactile Fremitus: Normal lung transmits a palpable vibratory sensation to the chest wall. This is referred to as fremitus and can be detected by placing the ulnar aspects of both hands firmly against either side of the chest while the patient says the words "Ninety-Nine." This maneuver is repeated until the entire posterior thorax is covered. The bony aspects of the hands are used as they are particularly sensitive for detecting these vibrations.
■ Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
listening for breath sounds: posterior
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
listening for breath sounds: lateral
Copyright © 2000 by W. B. Saunders Company. All rights reserved. p. 196.
MENU
back
listening for breath sounds: lateral ■
Copyright © 2000 by W. B. Saunders Company. All rights reserved. p. 196.
MENU
back
listening for breath sounds: anterior
Copyright © 2000 by W. B. Saunders Company. All rights reserved. p. 196.
MENU
back
Normal percussion notes: anterior
Copyright © 2000 by W. B. Saunders Company. All rights reserved. p. 198.
MENU
back
Normal percussion notes: posterior
Copyright © 2000 by W. B. Saunders Company. All rights reserved. p. 198.
MENU
back
Auscultation ■
■
■
breath sounds occur as a result of the movement of air through the theright trachea, ■ Visualize bronchi and alveoli. lung is divided into 3 lobes, the left, into Use diaphragm; have client breath two. Apex is at the through mouth, more deeply than usual. top; base at the bottom. Sounds are assessed side-toside; anterior and posterior. Copyright © 2000 Copyright by W. B.©Saunders 2000 by W. Company. B. Saunders All rights Company. reserved. All rights reserved.
The middle lobe is best assessed on the right side under the arm
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Normal breath sounds: Vesicular ■
; soft, low, heard in periphery and base of lungs.
soft, low, heard in periphery and base of lungs.
■
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Normal breath sounds: bronchovesicular ■
medium pitch, heard between scapula and anteriorly close to sternum.
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Normal breath sounds: bronchial ■
loud and harsh; heard over trachea. Abnormal when heard elsewhere (pneumonia, tumor).
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Abnormal breath sounds ■
Adventitious (abnormal) breath sounds occur when air passes through narrowed airways filled with fluid or mucus; superimposed over normal breath sounds.
■
Crackles, fine rales fine, high pitched crackling sound;
■
Rhonchi, course- low pitched, gurgling; moaning, snoring quality, clear with coughing Wheezes, high pitched, squeaky inspiratory, expiratory
■
http://depts.washington.edu/~physdx/pulmonary/tec h.html
■
http://www.med.ucla.edu/wilkes/lungintro.htm Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Assessment sites for the assessment of the precordium
Copyright © 2000 by W. B. Saunders Company. All rights reserved. p. 200.
MENU
back
■
Heart lies behind and to the left of the sternum. The upper portion or atria (BASE) lies to the back; the ventricles (APEX) points forward, the apex of the left ventricle actually touches the anterior chest wall near the left midclavicular line at or near the 5th left ICS. Known as point of maximal impulse (PMI) and is where apical beat is assessed. Impulse is a good index of heart size.
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
■
Known as point of maximal impulse (PMI) and is where apical beat is assessed. Impulse is a good index of heart size.
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
■
Aortic area- 2nd ICS to right of sternum (closure of the aortic valve loudest here).
■
Pulmonic area- 2nd ICS to left of sternum (closure of the pulmonic valve loudest here).
■
Tricuspid- 5th ICS left of sternal border (closure of tricuspid valve).
■
Mitral- 5th ICS left of the sternum just medial to MCL (closure of mitral valve).
■
http://medicine.ucsd.edu/c linicalmed/heart.htm
Copyright © 2000 by W. B. Saunders Company. All rights reserved. ■
back
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
■
Inspection- look for lift at apex.
■
Auscultation- Client should be assessed in supine position with head up to 45 deg.; examiner stands at right side. Use diaphragm for basic sounds; bell for murmurs and extra sounds.
■
Identify the heart rate, rhythm; bell for murmurs aortic, pulmonic, mitral
■ Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Auscultating Heart Sounds ■
http://www-medlib.med.utah.edu/kw/pharm/hyper_heart1.html
■
Blood flows from R. atrium to R. ventricle through the atrioventricular valve, the tricuspid. Blood flows from L. atrium to L. ventricle through the mitral valve. Blood passes from R. ventricle to pulmonary artery through the pulmonic valve and from the left ventricle to aorta through the aortic valve (semilunar valves). Events on the left side of the heart slightly precede those on the right.
■
http://www.austincc.edu/adnlev1/rnsgskills2online/physical_assessment_b/MVPNor mal.gif
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
MENU
back
Auscultating Heart Sounds ■
■
S1 produced by closure of the atrioventricular valves, mitral and tricuspid)- loudest at mitral area. The sound is a dull, low pitched “lub.” S2 (produced by closure of aortic and pulmonic valve) is higher pitched, shorter and is the “dub” sound. Heard best at the base (aortic and pulmonic areas). S-2 is normally louder than S-1
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
MENU
back
Auscultating Heart Sounds – S3 rapid filling of the ventricle with blood; heard following S-2. Can be normal in young adults and children; pathologic in elderly – S4 atrial contraction and thought to result from stiffened left ventricle; directly precedes S-1. Heard in elderly.
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
MENU
back
Auscultating Heart Sounds ■
Extra Heart Sounds snaps and clicks refer to valves: aortic and mitral stenosis, prosthetic valve – Murmurs: swishing or blowing sounds caused by o Forward flow through a steno tic valve o Increased flow through a normal valve o Backward flow through a valve that fails to close.
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
MENU
■
http://egeneralmedical.com/listohearmur.html http://depts.washington.edu/~physdx/heart/demo.html
■
to listen to sounds http://www.med.ucla.edu/wilkes/Physiology.htm
back
Cardiac Cycle
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Evaluating Heart Murmurs ■
Intensity
Peripheral Vascular Graded on a scale of 1 to 6System: Grade assessment I (barely audible) to Grade VI (loud and may be heard of BP, palpation of without the stethoscope). peripheral puses, inexpection of jugular Pattern quality and peripheral vessels and inspection of skin Location tissues to determine Radiation perfusion to the extremities. ■
■
■ ■ ■ ■
Posture
■ Copyright © 2000 by W. B. Saunders Company. All rights reserved.
MENU
back
■
Inspect neck for pulsations and jugular veins for distention. JVD refers to jugular venous distentionindex of function of the right atrium.
■
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
■
Advanced practitioners would ausculate the carotid artery for a bruit (blowing or swishing sound) and palpate a thrill (a vibrating sensation).
■ Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Inspect and palpate skin of hands, feet and legs ■
for color, temperature and edema. Unilateral coolness may be associated with decreased blood flow and should be correlated with pulse in that extremity.
■
Arterial insufficiency- cool extremity, dec. or absent pulse, color changes.
■
Venous insufficiency- normal temperature, normal pulses, color changes; skin changes. Copyright © 2000 by W. B. Saunders Company. All rights reserved.
back
Inspect and palpate skin of hands, feet and legs ■
Deep vein thrombosis (DVT)- Homan’s sign: Knee flexed- pain in calf with dorsiflexion of foot. Not performed if pt. is dx’d with thrombus.
■
Edema- fluid accumulation in the tissues; assess by pressing firmly with the thumbusually over shin or medial maleolus of foot. Graded on scale of 1+ - 4+.
■ Copyright © 2000 by W. B. Saunders Company. All rights reserved.
1
Physical Examination: Thorax
2
Thorax
3
Anterior Chest Landmarks
4
"Anterior"
5
Posterior Chest Landmarks
6
"Palpate – respiratory excursion"
7
"Percussion- adv"
8
Anterior Thorax
9
Lateral Chest Landmarks
10
Inspection
11
Palpation
12
"Tactile Fremitus"
13
listening for breath sounds: posterior
14
listening for breath sounds: lateral
15
listening for breath sounds: lateral
16
listening for breath sounds: anterior
17
Normal percussion notes: anterior
18
Normal percussion notes: posterior
19
Auscultation
20
"Visualize the right lung is..."
21
"The middle lobe is best..."
22 23
Auscultation
24
Normal breath sounds: Vesicular
25
Normal breath sounds: bronchovesicular
26
Normal breath sounds: bronchial
27
Abnormal breath sounds
28 29
Assessment sites for the assessment of the precordium
30
"Heart lies behind and to..."
31
"Known as point of maximal..."
32
"Aortic area- 2nd ICS to..."
33 34
"Inspection- look for lift at..."
35
Auscultating Heart Sounds
36
Auscultating Heart Sounds
37
Auscultating Heart Sounds
38
Auscultating Heart Sounds
39
Places to listen to sounds
40
Cardiac Cycle
41
Evaluating Heart Murmurs
42
"Peripheral Vascular System"
43
"Inspect neck for pulsations and..."
44
"Advanced practitioners would ausculate the..."
45
Inspect and palpate skin of hands, feet and legs
46
Inspect and palpate skin of hands, feet and legs
47
THE END
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