1. Brief Orientation to the Ultrasound Machine and Image Acquisition

1. Choose the appropriate probe and the preset based on the study you intend to perform.
2. For superficial structure, choose the linear probe. For deeper structures, choose the curvilinear or phased array probe.
3. Choose the exam preset that matches the area to be examined (for example, cardiac).
4. Orientate yourself to the probe indicator, which matches the indicator on the left side of the ultrasound machine screen.
5. To generate an image, apply gel to the probe and then position the probe on the patient above the organ of interest.
6. The hand of the ultrasound operator should be anchored to prevent the probe from sliding.
7. Optimize the image.
8. Adjust the depth so that the structure of interest is in the middle of the screen.
9. Adjust the gain so that the structure of interest is bright enough to clearly see without washing out the structures that should be anechoic.

2. Examination of the Thyroid

1. Review the palpation of the thyroid here: JoVE Video 10098: Thyroid Exam
2. Select the linear probe and the soft tissue preset on the ultrasound machine.
3. Have the patient in the seated position.
4. Use the ultrasound to identify and optimize the isthmus of the thyroid and right and left lobes in transverse view.
5. Identify the relation of the thyroid to the surrounding structures, including the sternocleidomastoid muscle and carotid artery.
6. Mark the level of the isthmus using a skin marking pen.
7. Turn the probe 90 degrees to obtain the sagittal view of the isthmus of the thyroid.
8. Ask the patient to swallow and observe the upward movement of the isthmus.
9. Remove the ultrasound probe, and palpate the thyroid guided by the skin marking and knowledge obtained through visualization of surrounding structures.

3. Examination of the Lung

1. Review the percussion of the lung here: JoVE Video 10041: Respiratory Exam II: Percussion and Auscultation
2. Select the curvilinear probe and the abdominal preset on the ultrasound machine.
3. Have the patient in the seated position.
4. With the probe indicator directed towards the patient's head, use the ultrasound to identify and optimize the interface between the lungs and abdominal organs on the posterior thorax. This represents the position of the diaphragm.
5. Note the movement of the diaphragm with respirations.
6. Mark the level of the diaphragm at exhalation and inhalation.
7. Use percussion to identify the excursion of the diaphragm with inhalation and exhalation.

4. Examination of the Heart

1. Review the auscultation of the heart here: JoVE Video 10124: Cardiac Exam II: Auscultation and JoVE Video 10135: Cardiac Exam III: Abnormal Heart Sounds.
2. Select the phased array probe and the cardiac preset on the ultrasound machine. For the purpose of learning the physical exam, have the ultrasound screen indicator on the left side of the screen.
3. Place the patient in the left lateral decubitus position.
4. In approximately the 3^rd or 4^th intercostal space, just left of the sternum, and with the probe indicator directed towards the patient’s right shoulder, use the ultrasound to obtain and optimize the parasternal long axis view of the heart.
5. Obtain a short video clip of the ultrasound image.
6. In the video, note the movement of the mitral and aortic valves. Correlate this to S1 (closure of the mitral and tricuspid valve) and S2 (closure of the aortic and pulmonic valves).
7. Review the timing of the murmurs of aortic regurgitation and stenosis and mitral regurgitation and stenosis while observing the movement of the valves.
8. Obtain the parasternal long axis view again and auscultate the heart while observing the movement of the valves.
9. Next, palpate the point of maximal impulse and place the probe at that spot with the indicator directed to the right hip to find the apical 4-chamber view of the heart.
10. Capture a video clip of the apical 4-chamber view.
11. In the video clip, observe the opening and closing of the mitral and tricuspid valves and correlate with S2 and the murmurs of mitral regurgitation and stenosis and tricuspid regurgitation.
12. Observe the filling (diastole) and emptying (systole) of the ventricles with each cardiac cycle and time that with the opening and closing of the mitral valve.
13. Correlate the S3, and S4 heart sounds with early and late diastole.

5. Examination of the Liver

1. Review the percussion and palpation of the liver here: JoVE Video 10090: Abdominal Exam II: Percussion and JoVE Video 10089: Abdominal Exam III: Palpation 
2. Select the curvilinear probe and the abdominal preset on the ultrasound machine.
3. Have the patient in the supine position.
4. With the probe indicator directed towards the patient's head, use the ultrasound to identify and optimize the liver in a sagittal plane in the midclavicular line.
5. Note the movement of the liver with respiration.
6. Freeze and acquire the image. Measure the vertical span of the liver.
7. Use the ultrasound to again identify the liver in a sagittal plane — mark the level of the diaphragm and the lower edge of the liver.
8. Percuss the liver span in the midclavicular line and compare the measurement made using percussion and ultrasound.
9. Use the reference mark of the lower edge of the liver identified by ultrasound to guide the palpation of the liver edge.

6. Examination of the Spleen

1. Review the percussion and palpation of the spleen here: JoVE Video 10090: Abdominal Exam II: Percussion and JoVE Video 10089: Abdominal Exam III: Palpation 
2. Select the curvilinear probe and the abdominal preset on the ultrasound machine.
3. Have the patient in the supine position.
4. With the probe indicator directed towards the patient's head, use the ultrasound to identify and optimize the spleen in a coronal plane in the left mid-axillary line.
5. Note the movement of the spleen with respiration.
6. Attempt to palpate the spleen synchronously with imaging. Note how the spleen moves closer to the palpating hand with each inhalation.
7. Move the ultrasound probe to the anterior axillary line and find the lowest intercostal space by decreasing the depth and sliding to the lowest rib. Once identified, increase the depth.
8. Ask the patient to inhale fully and observe the movement of the spleen under the probe.
9. Using palpation alone, identify the lowest intercostal space in the anterior axillary line and percuss using Castell's method.