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Research

2D NMR: Overview of Heteronuclear Correlation Techniques

Heteronuclear correlation spectroscopy is an analytical technique that investigates the coupling between different types of nuclei, often a proton and an X-nucleus, such as carbon-13 or nitrogen-15. This method is commonly used in nuclear magnetic resonance (NMR) spectroscopy to gain insights into complex chemical compounds&#39; structural and compositional aspects. A typical heteronuclear correlation spectrum displays X-nucleus chemical shifts on one axis and a proton spectrum on the other axis. Cross-peaks reveal the connection between specific protons and X-nuclei.
The main heteronuclear correlation experiments include HETCOR, HSQC, HMQC, and HMBC. HSQC, HMQC, and HMBC record the proton spectrum, whereas the X-nucleus spectrum is recorded by standard heteronuclear correlation spectroscopy or HETCOR. The HETCOR-HMQC-HSQC group of experiments cannot detect X-nuclei without an attached proton. HETCOR is used when ultrahigh peak resolution is required along the X-nucleus axis.
The heteronuclear single quantum correlation technique, or HSQC, investigates proton-to-X-nucleus single bond correlations. In an HSQC experiment, polarization is transferred from a proton nucleus to a neighboring X-nucleus and then back to the proton nucleus. The signal from the proton nuclei is then recorded. HSQC generates a spectrum like that of heteronuclear multiple-quantum correlation spectroscopy or HMQC but uses a different suppression method, providing better X-nucleus resolution along the axis.
Heteronuclear multiple-bond correlation, or HMBC, is a proton-detected experiment, like HMQC but with a longer initial delay time. This experiment is used to observe long-range proton to X-nucleus connectivity separated by 2-3 bonds, with some experiments going out to 4 or 5 bonds. In an HMBC experiment, direct one-bond correlations are suppressed as part of the sequence. The spectra of HMBC give rise to cross peaks that correlate which protons are coupled to what other specific X-nucleus is more than one bond away. The gradient HMBC (gHMBC) pulse sequence offers better suppression of interfering signals, making it particularly useful for analyzing complex molecules with overlapping signals.

Heteronuclear correlation spectroscopy is an analytical technique that investigates the coupling between different types of nuclei, often a proton and an ...

2D NMR: Heteronuclear Single-Quantum Correlation Spectroscopy (HSQC)

Heteronuclear single-quantum correlation spectroscopy (HSQC) is a 2D NMR technique that reveals one-bond correlations between hydrogen and a heteronucleus. The HSQC experiment is similar to the heteronuclear correlation experiment (HETCOR) but is more sensitive. In the HSQC spectrum, the proton chemical shift is plotted on the horizontal F2 axis, while the 13C chemical shift is plotted on the vertical F1 axis. The corresponding proton and 13C spectra are also shown. The HSQC contour plot does not have any diagonal peaks. All the cross-peaks indicate the protons directly attached to each carbon in a molecule. Similar to the COSY spectrum, imaginary lines are drawn in horizontal and vertical directions to identify the correlated peaks.
For example, the HSQC spectrum of 2-chlorobutane has a carbon signal at 11 ppm that can be assigned to the shielded methyl group and correlated to the proton multiplet at 1.01 ppm. The carbon signal at 24.8 ppm arises from the deshielded methyl group, which correlates to the proton multiplet at 1.52 ppm. Similarly, the methylene carbon signal at 33.3 ppm and methine carbon signal at 60.4 ppm correlate to the multiplets at 1.72 and 3.96 ppm, respectively.&#160; HSQC is a very useful technique for structurally elucidating complex molecules and is routinely used in protein NMR studies.

Heteronuclear single-quantum correlation spectroscopy (HSQC) is a 2D NMR technique that reveals one-bond correlations between hydrogen and a ...

Double Resonance Techniques: Overview

Double resonance techniques in Nuclear Magnetic Resonance (NMR) spectroscopy involve the simultaneous application of two different frequencies or radiofrequency pulses to manipulate and observe two distinct nuclear spins. One important application of double resonance is spin decoupling, which selectively suppresses coupling with one type of nucleus while observing the NMR signal from another nucleus, simplifying the spectrum and enhancing resolution.
Spin decoupling is usually achieved by irradiating the sample atoms with a suitable radio frequency (rf) pulse sequence, effectively eliminating all the coupling with one nuclide. This simplifies the observed spectrum, making it easier to analyze and understand the relationships between different nuclei.
Double resonance experiments can be classified as heteronuclear or homonuclear, depending on whether the two sets of nuclei are of different isotopes or the same isotope, respectively. They can also be selective or nonselective, depending on whether the irradiating frequency covers only a portion or all of the resonance frequencies.
In nonselective heteronuclear decoupling, samples are exposed to an appropriate radiofrequency range to remove all coupling with one nuclide. However, increased external field strengths necessitate more powerful irradiation across broader frequency ranges. In certain instruments, continuous irradiation creates enough heat to cause damage to thermally sensitive samples.
To overcome these problems, modern methods using a series of pulses and exact timing delays, like J-modulated spin echo pulse sequences, can be employed to eliminate or adjust coupling effects within the spectrum.
For example, the attached proton transfer (APT) experiment applies a J-modulated spin echo pulse sequence to focus on the phase of detected carbon signals. Carbon atoms attached to an even number of protons exhibit positive signals in the spectrum, while those bonded to an odd number of protons appear as negative signals.
It utilizes a combination of a 180&#176; proton pulse and broadband decoupling to simplify spectral interpretation and assign multiplicities. The 180&#176; pulse is applied to the protons during the APT experiment. Its role is to refocus the spin coupling evolution that naturally occurs due to interactions between protons and carbons.
Specifically, after the 90&#176; pulse creates transverse magnetization, the 180&#176; pulse ensures that the effects of coupling are frozen during the initial period where the decoupler is turned off. This means the chemical shifts evolve only during the time 1/J&#8203; (the coupling constant period) after the first 180&#176; pulse.
By carefully timing this pulse sequence, the experiment isolates carbon multiplicities by utilizing the J-coupling between carbons and their attached protons. After the coupling evolution period (1/J&#8203;), broadband decoupling is turned on. This removes the J-coupling signals, collapsing multiplets into single peaks for each carbon resonance.
The decoupling ensures that carbon signals are free of splitting, allowing for a clear differentiation of signals based on phase (positive or negative) rather than splitting patterns.
The APT technique selectively enhances carbon signals, providing valuable information about carbon-proton connectivity, the number of attached hydrogen atoms, and the overall molecular structure.

Double resonance techniques in Nuclear Magnetic Resonance (NMR) spectroscopy involve the simultaneous application of two different frequencies or ...

Insensitive Nuclei Enhanced by Polarization Transfer (INEPT)

Insensitive Nuclei Enhanced by Polarization Transfer (INEPT) is an advanced Nuclear Magnetic Resonance (NMR) technique specifically designed to detect and enhance the signals of low-abundance nuclei, such as carbon-13 and nitrogen-15, in small molecules. The fundamental principle behind INEPT is the transfer of polarization from a more abundant and highly polarizable nucleus, typically hydrogen-1, to the low-abundance nucleus of interest. This process effectively boosts the NMR signal of the low-abundance nuclei, making them more easily detectable.
The INEPT technique involves a series of carefully timed radiofrequency (RF) pulses applied to the sample. These RF pulses excite the more abundant nuclei, causing them to align their spins in a specific manner. Through the process of spin coupling, the polarization of the more abundant nuclei is then transferred to the low-abundance nuclei. As a result, the NMR signal of these low-abundance nuclei is significantly enhanced, allowing for a more detailed analysis of the molecular structure.
Various pulse sequences have been developed to improve the observability of these low-abundance nuclei when coupled to a high-receptivity nucleus. The INEPT pulse sequence combines a spin echo and selective population inversion, which includes 90&#176; and 180&#176; pulses on the high-sensitivity (the I spins) and low-sensitivity nuclei (the S spins), respectively. Coupling-constant-based delays between pulses facilitate magnetization transfer through space or bond interactions. Additional RF pulses and delays invert the low-gamma magnetization, producing an observable NMR signal. The net result is an enhanced NMR signal from low-gamma nuclei that would otherwise be challenging to detect.
Various pulse sequences have been developed to improve the detection of low-abundance nuclei when coupled with high-receptivity nuclei such as protons. The INEPT sequence yields enhanced signals for insensitive nuclei, with half of the CH group producing negative peaks and the other half positive peaks. This pattern allows for discrimination between different types of carbon-hydrogen bonds within the molecule.
Decoupling methods can be employed to enhance sensitivity and resolution in distinguishing various carbon-hydrogen bonds, making INEPT an invaluable tool in the chemical and pharmaceutical industries.

Insensitive Nuclei Enhanced by Polarization Transfer (INEPT) is an advanced Nuclear Magnetic Resonance (NMR) technique specifically designed to detect and ...

Two-Dimensional (2D) NMR: Overview

The 1D NMR spectrum of large and complex molecules like natural products has complicated splitting patterns and overlapping signals, which can be easily interpreted using 2-dimensional (2D) NMR. Unlike 1D NMR, 2D NMR has two frequency axes that provide the coupling information between the nucleus A and nucleus B in a molecule. The process from which 2D spectra are obtained has four steps.
The first step is the preparation period, during which nucleus A is excited with a radiofrequency pulse. The second step is the evolution or wait period t1, which is incremented systematically, and no data is observed during this period. The next step is the mixing period, in which a second radiofrequency pulse is introduced, which transfers the magnetization to the spins of nucleus B. In the last step, the magnetization of nuclear spins from B is detected during the acquisition time t2 for each t1. Time domains t1 and t2 are Fourier transformed into frequency domains f1 and f2, and these correspond to two dimensions of 2D spectra, while the third dimension is the intensity. In 2D experiments, coupling between the same kind of nucleus is called homonuclear 2D experiments, whereas coupling between two types of nucleus is called heteronuclear 2D experiments. 2D spectra can be displayed as stacked or contour plots. When presented as stacked plots, 2D spectra are difficult to interpret. The contour plot is the horizontal cross-section of a stacked plot where the size of the circles shows the signal intensity. Its interpretation is straightforward and it is preferred for data analysis.

The 1D NMR spectrum of large and complex molecules like natural products has complicated splitting patterns and overlapping signals, which can be easily ...

2D NMR: Overview of Homonuclear Correlation Techniques

Homonuclear correlation spectroscopy (COSY) is a powerful technique used in Nuclear Magnetic Resonance (NMR) spectroscopy to study the correlations between nuclei of the same type within a molecule. It provides information about scalar couplings between adjacent nuclei, which helps determine connectivity and structural information. There are several COSY variants, each with its unique strengths and experimental parameters.
COSY90 is the standard two-dimensional (2D) COSY experiment that utilizes a second 90-degree pulse to achieve high sensitivity and resolution. It excels in analyzing small to medium-sized molecules and provides information on directly coupled protons. COSY45, similar to COSY90, uses 45-degree pulses instead of 90-degree pulses. This results in reduced sensitivity but improved resolution.
Long-range COSY (LR-COSY) extends the COSY experiment to detect scalar couplings between nuclei further apart in the molecule. It achieves this by combining multiple pulse sequences and magnetization transfers.
Relayed COSY is a variant of COSY that adds extra pulses to the standard pulse sequence to produce cross-peaks between cross-peaks, showing specific molecular connections hidden by overlapping signals.
TOCSY (Total Correlation Spectroscopy), also known as HOHAHA (Homonuclear Hartmann-Hahn Spectroscopy), reveals all through-bond connectivity between all coupled nuclei. TOCSY is especially useful for analyzing molecules with overlapping signals and complex coupling patterns.
NOESY (Nuclear Overhauser Effect Spectroscopy) measures the nuclear overhauser effect, which arises from dipole-dipole interactions between nuclei. It provides information about spatial proximity and can be used to determine the three-dimensional structure of a molecule.
ROESY (Rotating-frame Overhauser Enhancement Spectroscopy) is similar to NOESY but employs a different mechanism to obtain through-space correlations. It provides information about spatial proximity and is particularly useful for studying molecules with weak NOE signals.
In conclusion, choosing a COSY variant depends on the molecule or reaction under investigation and the desired information. The right COSY variant can be determined based on molecular size, coupling complexity, and the need for spatial or long-range connectivity data.

Homonuclear correlation spectroscopy (COSY) is a powerful technique used in Nuclear Magnetic Resonance (NMR) spectroscopy to study the correlations ...

2D NMR: Homonuclear Correlation Spectroscopy (COSY)

Homonuclear correlation spectroscopy, or COSY, is a 2-dimensional NMR technique that provides information about coupled protons. Typically, the geminal and vicinal coupling are observed. For example, consider the COSY spectrum of ethyl acetate, where its 1D proton NMR spectrum is plotted along the vertical and horizontal axes with their corresponding chemical shift scale. Three spots on the diagonal corresponding to the three peaks in the 1D proton spectrum are called diagonal peaks. The COSY spectrum is symmetric about the diagonal, with signals above and below the diagonal called cross-peaks or off-diagonal peaks. An imaginary line is drawn from diagonal peaks parallel to the horizontal axis, leading to a cross peak. A vertical line is then drawn from the same cross peak towards the diagonal peak to correlate the peaks. The off-diagonal peaks correlating the multiplets at 1.25 and 4.2 ppm indicate that the methyl protons are coupled to the methylene protons. The signal at 2 ppm is not associated with cross-peaks because the protons are not involved in homonuclear coupling. A COSY spectrum is useful when overlapping multiplets complicate the corresponding 1D spectrum.

Homonuclear correlation spectroscopy, or COSY, is a 2-dimensional NMR technique that provides information about coupled protons. Typically, the geminal ...

&sup1;H NMR of Labile Protons:  Deuterium (&sup2;H) Substitution

This lesson illustrates the role of deuterium substitution in simplifying the NMR spectrum of compounds comprising labile protons. One method employed is the use of deuterium. Amongst the three isotopes of hydrogen, deuterium (2H) has a nucleus composed of one proton and one neutron. When the D2O solvent is added to a pure dry ethanol solution, its labile proton is substituted with deuterium.
<img alt="Figure1" src="/files/ftp_upload/12280/12280-PT_Figure_1.svg" style="text-align: center; height: 700px;" />
Figure 1. The comparison of the proton NMR spectra of pure dry ethanol and the same in D2O solvent.
The signals from deuterium are not observed in a proton NMR spectrum, as deuterium&#8211;proton coupling is negligible, and no spin-spin splitting occurs between them. As shown in Figure 1, the NMR spectra of pure ethanol and ethanol in deuterium, the disappearance of the triplet in the latter, confirms that it corresponds to the labile &#8211;OH proton. Furthermore, the methylene protons that initially showed up as a multiplet transform to a quartet, proving that the multiplet is due to the coupling with the &#8211;OH proton and the methyl protons.

This lesson illustrates the role of deuterium substitution in simplifying the NMR spectrum of compounds comprising labile protons. One method employed is ...

&sup1;H NMR of Labile Protons: Temporal Resolution

Protons bonded to heteroatoms such as nitrogen and oxygen exhibit a range of chemical shift values. This is due to the varying degree of hydrogen bonding between the proton and the heteroatom in other molecules. The extent of hydrogen bonding affects the electron density around the proton, thereby giving different chemical shift values for the protons in the proton NMR spectrum.
The &#8211;OH proton in alcohols typically appears in the range of &#948; 2 to 5 ppm but can vary depending on the specific alcohol and conditions. This &#8211;OH proton undergoes rapid proton exchange with other molecules and is referred to as a labile proton. So, the exact &#948; value of the &#8211;OH proton and the spin-spin coupling involving the &#8211;OH proton and the other protons in the alcohol depends on the rate of the &#8211;OH proton exchange. The proton exchange rate, in turn, depends on multiple factors, including the purity of the alcohol sample, temperature, and solvent.
<img alt="Figure1" src="/files/ftp_upload/12279/12279-PT_Figure_1.svg" style="text-align: center; height: 350px;" />
Figure 1. The triplet of a &#8211;OH proton in the proton NMR spectrum of neat ethanol.
For example, the &#8211;OH proton exchange in a pure dry ethanol sample is very slow on the NMR time scale, giving enough time for the spin-spin coupling. Consequently, as depicted in Figure 1, the proton NMR spectrum of pure dry ethanol shows a triplet for the &#8211;OH proton due to the spin-spin coupling with adjacent methylene protons. The methylene protons are seen as a multiplet due to the coupling with the &#8211;OH proton and the methyl protons.
The presence of trace amounts of an acid or base increases the proton exchange rate. The proton exchange becomes rapid, and the NMR spectrometer only records an average of all the possible environments for the &#8211;OH proton.
<img alt="Figure2" src="/files/ftp_upload/12279/12279-PT_Figure_2.svg" style="text-align: center; height: 325px;" />
Figure 2. The broad singlet of a &#8211;OH proton in the proton NMR spectrum of neat ethanol.
As a result, as recorded in Figure 2, the &#8211;OH proton exhibits a broad singlet. The protons from the adjacent methylene group present a quartet where the splitting is caused only by the adjoining methyl group.

Protons bonded to heteroatoms such as nitrogen and oxygen exhibit a range of chemical shift values. This is due to the varying degree of hydrogen bonding ...

Nuclear Overhauser Enhancement (NOE)

Irradiation of a spin-active nucleus causes an increase or decrease in the signal intensity of neighboring nuclei that are not necessarily chemically bonded or involved in J-coupling. &#160;This phenomenon, called the Nuclear Overhauser Enhancement (NOE), results from through-space interactions between the nuclear spins. The NOE effect decreases with increasing internuclear distance and is generally not observed beyond 4 angstroms. In NOE, dipole-dipole interactions between neighboring spin-active nuclei result in the transfer of nuclear spin polarization. These interactions can cause an increase or decrease in the signal intensity, which results in a positive or negative NOE, respectively.
NOE can be applied to improve the signal intensity of less sensitive nuclei such as carbon-13. Proton-decoupled carbon-13 spectra show a positive NOE effect, where the carbon signal intensities are substantially increased compared to those in proton-coupled spectra.
Targeted irradiation of specific nuclei can also reveal through-space proximity, which helps confirm stereochemistry and verify spectral peak assignments. The NOE effect is also applied in 2D NMR experiments, such as Nuclear Overhauser Effect Spectroscopy (NOESY), to determine the 3D structure of proteins.

Irradiation of a spin-active nucleus causes an increase or decrease in the signal intensity of neighboring nuclei that are not necessarily chemically ...

&sup1;H NMR of Conformationally Flexible Molecules: Variable-Temperature NMR

The axial and equatorial protons in cyclohexane can be distinguished by performing a variable-temperature NMR experiment. In this process, except for one proton, the remaining eleven protons are replaced by deuterium. The deuterium substitution avoids the possible peak splitting caused by the spin-spin coupling between the adjacent protons. The remaining proton flips between the axial and equatorial positions.
<img alt="Figure1" src="/files/ftp_upload/13016/13016-PT_Figure_1.svg" style="text-align: center; height: 480px;" />
Figure 1. The temperature-dependent proton NMR spectra of cyclohexane.
Figure 1 depicts the proton NMR spectrum of the deuterium substituted sample, recorded at various temperatures. At room temperature, the rapid ring flipping of cyclohexane results in a single sharp peak. As the temperature is lowered to &#8722;60&#176;C, the rate of chair-chair interconversion reduces, resulting in the broadening of the peak.
Further lowering of the temperature broadens the peak, forming a saddle that splits into two peaks. On reaching a temperature lower than &#8722;89&#176;C, two sharp, well-resolved peaks corresponding to the equatorial and axial protons are formed. The peaks corresponding to the equatorial and axial protons occur at &#948; 1.62 and 1.14, respectively. At such low temperatures, the rate of chair-chair interconversion is reduced significantly, enabling the detection of the two distinct sets of protons on the NMR time scale.

The axial and equatorial protons in cyclohexane can be distinguished by performing a variable-temperature NMR experiment. In this process, except for one ...

&sup1;H NMR of Conformationally Flexible Molecules: Temporal Resolution

At room temperature, the chair conformer of cyclohexane undergoes rapid ring flipping between two equivalent chair conformers at a rate of approximately 105 times per second. These two chair conformers are in equilibrium. The rapid ring flipping results in the interconversion of the axial proton to an equatorial proton and an equatorial to the axial proton. Such interconversions are too rapid and cannot be detected on the NMR timescale. Hence, the NMR spectrometer cannot distinguish between the axial and equatorial protons, resulting in a single peak at &#948; 1.4.
Similarly, NMR averages all the conformations of any molecule with rapid conformational equilibria. For example, the CH3 protons in bromoethane have a single resonance and coupling constant for splitting by the CH2 protons due to the rapid internal rotation of the carbon-carbon bond. Lastly, besides conformational equilibria, the time-averaging effect of NMR spectroscopy is also observed in some chemical reactions.

At room temperature, the chair conformer of cyclohexane undergoes rapid ring flipping between two equivalent chair conformers at a rate of approximately ...

Chemical Ionization (CI) Mass Spectrometry

The molecular ion peak of a molecule in the mass spectrum provides vital information for molecular identification. However, conventional electron impact ionization can lead to the rapid dissociation of some molecular ions before they reach the detector. A milder ionization method is required to increase the lifetime of such ionized analyte molecules. Chemical ionization (CI) is a gas-phase protonation reaction useful for mass-analyzing analyte molecules that are easily protonated to yield the corresponding conjugate acid. In this process, the sample is mixed with an excess reagent gas, which ensures the electron impact occurs primarily on the reagent gas. The charged species formed from the reagent protonates the analyte molecule, producing a relatively stable protonated analyte (conjugate acid) compared to the molecular ion. This results in an M+1 peak in the mass spectrum. The conjugate acid may then undergo fragmentation that generates additional signals.
For example, the CI of di-sec-butyl ether in methane gas illustrates this process. When the ether is mixed with excess methane gas as a reagent, electron impact occurs on methane rather than the ether. The resulting methane radical cation can react with another methane molecule to generate a methane radical and a methanium ion. The methanium ion is a source of gas-phase protons, which can protonate the ether to form its conjugate acid. The sequential reactions during the chemical ionization of di-sec-butyl ether are depicted in Figure 1.
<img alt="Figure1" src="/files/ftp_upload/12300/12300_PT_Figure_1.svg" style="text-align: center; height: 175px;" />
Figure 1: Chemical ionization of di-sec-butyl ether methane mixture.
This conjugate acid of the ether (m/z = 131) is relatively more stable than the molecular ion (m/z = 130) of ether formed via the conventional electron impact ionization. In the traditional route, the molecular ion undergoes fragmentation via &#945; cleavage, giving a signal at m/z = 101. Figure 2 illustrates the reactions that occur during electron impact ionization directly on di-sec-butyl ether.
<img alt="Figure2" src="/files/ftp_upload/12300/12300_PT_Figure_2.svg" style="text-align: center; height: 175px;" />
Figure 2: Electron impact ionization of di-sec-butyl ether and fragmentation of the molecular ion.
So, the mass spectra of di-sec-butyl ether ionized via CI feature an M+1 peak at m/z = 131. On the other hand, mass spectra of di-sec-butyl ether ionized via electron impact ionization do not show any peak at the m/z value of its molecular weight. Figures 3a and 3b show the mass spectra of di-sec-butyl ether ionized via the electron impact and chemical ionization methods, respectively.
<img alt="Figure3" src="/files/ftp_upload/12300/12300_PT_Figure_3.svg" style="text-align: center; height: 225px;" />
Figure 3:&#160;a) No m/z = 130 peak is visible in the mass spectrum obtained via electron impact ionization of di-sec-butyl ether. b) The m/z = 131 peak is clearly visible in the mass spectrum obtained via chemical ionization of di-sec-butyl ether.

The molecular ion peak of a molecule in the mass spectrum provides vital information for molecular identification. However, conventional electron impact ...

Electrospray Ionization (ESI) Mass Spectrometry

Higher molecular weight biomolecules are nonvolatile compounds that may decompose before ionizing or vaporizing during mass analysis with conventional electron impact ionization methods. Accordingly, electrospray ionization (ESI) is the favored method for vaporizing and ionizing biomolecules as it circumvents rapid fragmentation and enables the recording of mass signals for the entire biomolecule.
ESI utilizes electrical energy to transfer ions from the liquid phase of the sample into the gaseous phase. The analyte biomolecule is premixed with an ionic liquid&#8212;a nonmolecular compound serving as the ionization source. The solution is sprayed through a high-voltage capillary to generate a fine aerosol. The voltage difference applied between the capillary and the entrance of the analysis chamber causes the movement of charged droplets toward the analysis chamber. The ionic liquid from the aerosol evaporates during this movement, leaving behind a variably protonated or ionized analyte molecule. These charged species are detected in the mass spectrum at an m/z value equivalent to the sum of the analyte molecule&#39;s molecular mass and the ions&#39; molecular weight from the ionic liquid associated with the analyte molecule.
The position of mass signals varies depending on the type of cations present in the ionic liquid. For example, the presence of sodium ions in the ionic liquid leads to an (M+23) peak in the mass spectra, while the presence of a proton results in an (M+1) peak.

Higher molecular weight biomolecules are nonvolatile compounds that may decompose before ionizing or vaporizing during mass analysis with conventional ...

Mass Spectrometry: Aldehyde and Ketone Fragmentation

In mass spectrometry, the fragmentation of aliphatic aldehydes and ketones generally occurs through three key mechanisms: &#945;-cleavage, inductive cleavage, and the McLafferty rearrangement.
<ol>
	<li>&#945;-Cleavage 
	&#945;-Cleavage is a common fragmentation in carbonyl compounds where the bond adjacent to the carbonyl group is broken. This process produces an alkyl radical and an acylium cation, which is often detected in the mass spectrum due to its stability.</li>
	<li>Inductive Cleavage 
	In inductive cleavage, fragmentation yields an acyl radical and an alkyl cation. This occurs when electrons are drawn toward the carbonyl, weakening adjacent bonds and resulting in a distinctive fragmentation pattern. For example, in the mass spectrum of 5-methyl-2-hexanone, inductive cleavage produces an alkyl cation at a mass-to-charge (m/z) ratio of 71.</li>
	<li>McLafferty Rearrangement 
	The McLafferty rearrangement is a specific fragmentation pattern for carbonyl compounds with &#947;-hydrogen (hydrogen on the third carbon from the carbonyl group). The molecule undergoes a six-membered cyclic transition in this rearrangement, yielding a radical cation and a neutral alkene. For 5-methyl-2-hexanone, this rearrangement results in a peak at m/z 58.</li>
</ol>
Example: Fragmentation of 5-methyl-2-hexanone 
In the mass spectrum of 5-methyl-2-hexanone, the molecular ion undergoes these fragmentation patterns:
<ol style="list-style-type: circle;">
	<li>Inductive cleavage produces an alkyl cation at m/z 71.</li>
	<li>&#945;-Cleavage results in the base peak at m/z 43.</li>
	<li>McLafferty rearrangement creates a distinct peak at m/z 58.</li>
</ol>
An additional diagnostic feature in aldehydes is the M&#8722;1 peak, which arises due to the &#945;-cleavage of the aldehyde proton. In mass spectrometric analysis, this peak can help identify aldehydes, specifically among other carbonyl compounds.
Understanding these fragmentation pathways is crucial for interpreting mass spectra, particularly in identifying functional groups and distinguishing between similar compounds.

In mass spectrometry, the fragmentation of aliphatic aldehydes and ketones generally occurs through three key mechanisms: &#945;-cleavage, inductive ...

Mass Spectrometry: Alkyl Halide Fragmentation

Chlorine isotopes exist as 35Cl and 37Cl in a 3:1 ratio, while bromine isotopes exist as 79Br and 81Br in a 1:1 ratio. The mass spectrum of alkyl halides typically produces two distinct molecular ion peaks, the molecular ion peak, [M], and the molecular ion plus two, [M + 2] peak. The relative heights of these two peaks are proportional to the isotopic abundance ratios of the halide. For example, 2&#8208;chloropropane and 1&#8208;bromopropane display two peaks with relative peak heights in a 3:1 and 1:1 ratio, respectively.
Alkyl halides typically lose a non-bonding electron from the halogen to form molecular ions. The base peak results from the heterolytic cleavage of the carbon&#8211;halogen bond, where the bonding electrons go to the most electronegative atom, forming a cation and halogen atom. Interestingly, the &#9082;-cleavage is observed only in alkyl chlorides, not alkyl bromides. In alkyl chlorides, the&#160; C&#8211;Cl and C&#8211;C bonds exhibit similar strengths, while in alkyl bromides, the C&#8211;Br bond is weaker than the C&#8211;C bond. Consequently, the alkyl chlorides form a stable cation, where the positive charge is shared between the two atoms.
While less commonly discussed, fluoroalkanes and iodoalkanes exhibit unique fragmentation behavior. Fluoroalkanes, due to the strength of the C&#8211;F bond and the presence of only one isotope (19F), show limited fragmentation and lack isotopic peaks. Iodoalkanes, with their weak C&#8211;I bond and a single isotope (127I), predominantly fragment by losing iodine, resulting in simpler spectra with less isotopic splitting.

Chlorine isotopes exist as 35Cl and 37Cl in a 3:1 ratio, while bromine isotopes exist as 79Br and 81Br in a 1:1 ratio. The mass spectrum of alkyl halides ...

Matrix-Assisted Laser Desorption Ionization (MALDI)

Matrix-assisted laser desorption ionization (MALDI) is a powerful analytical technique used in mass spectrometry. It enables the identification and characterization of various biomolecules, including proteins, peptides, nucleic acids, and carbohydrates. MALDI spectrometry is widely employed in biological and medical research, as well as in fields like pharmacology and biochemistry.
The analyte of interest, a biomolecule or a mixture of biomolecules, is mixed with a suitable matrix material. The matrix is usually an organic compound, such as a small organic acid or a crystalline substance, that facilitates ionization. This analyte-matrix mixture is then deposited onto a target surface, inserted into the mass spectrometer, and dried. During drying, the matrix forms small crystals that incorporate the analyte molecules within their structure.
Once the sample is prepared, a pulsed laser is directed onto the target surface. The matrix molecules absorb the laser beam energy, causing them to heat up and vaporize rapidly. This process is known as laser desorption. As the matrix molecules vaporize, they carry the embedded analyte molecules. The vaporized analyte molecules become ionized through a process called proton transfer. The proton transfer occurs between the matrix and the analyte molecule. The matrix molecule donates a proton to the analyte molecule, resulting in the formation of protonated ions. The analyte ions are then accelerated by an electric field and further separated based on their mass-to-charge ratio in a time-of-flight mass analyzer.
The mass spectrum obtained from MALDI spectrometry provides valuable information about the mass and relative abundance of the analyzed biomolecules.

Matrix-assisted laser desorption ionization (MALDI) is a powerful analytical technique used in mass spectrometry. It enables the identification and ...

Mass Spectrometry: Carboxylic Acid, Ester, and Amide Fragmentation

The fragmentation patterns observed for compounds such as carboxylic acids, esters, and amides in the mass spectra include &#9082;-cleavage and McLafferty rearrangement. Fragmentation by &#9082;-cleavage preferentially occurs at the carbon-carbon bond at the &#9082;-position next to the carboxylic group to generate a neutral radical and a cation. Long chain compounds with hydrogen at their &#947;-carbon undergo McLafferty rearrangement to give a radical cation and a neutral alkene.
For example, the fragmentation of butyramide is demonstrated in Figure 1. The molecular ion peak of butyramide, which contains one nitrogen atom, shows an odd mass-to-charge ratio of 87. Fragmentation of butyramide molecular ion by &#9082;-cleavage produces a cation at a mass-to-charge ratio 44. In addition to &#9082;-cleavage, butyramide molecular ion also undergoes fragmentation via McLafferty rearrangement. The base peak at the mass-to-charge ratio 59 arises due to McLafferty rearrangement.
<img alt="Figure1" src="/files/ftp_upload/13051/13051_PT_Figure_1.svg" style="text-align: center; height: 250px;" />

The fragmentation patterns observed for compounds such as carboxylic acids, esters, and amides in the mass spectra include &#9082;-cleavage and McLafferty ...

Mass Spectrometry: Aromatic Compound Fragmentation

Upon ionization, aromatic compounds generate a molecular ion that is observed as a prominent peak in their mass spectra. For example, the molecular ion peak for benzene appears at a mass-to-charge ratio of 78, while toluene is observed at a mass-to-charge ratio of 92. The molecular ion benzene is highly stable and does not readily undergo further fragmentation due to the significant amount of energy required to disrupt the aromatic stability of the benzene ring. In contrast, the molecular ion of alkyl&#8208;substituted benzenes, such as toluene, can undergo fragmentation by losing a hydrogen atom, forming a benzylic carbocation. This carbocation can rearrange to form the resonance-stabilized tropylium cation, which appears in the mass spectra as a strong peak. In the case of toluene, this strong peak is observed at a mass-to-charge ratio of 91.

Upon ionization, aromatic compounds generate a molecular ion that is observed as a prominent peak in their mass spectra. For example, the molecular ion ...

Mass Spectrometry: Alcohol Fragmentation

Alcohols (R-OH) ionize to lose one non-bonded electron from the oxygen atom, forming molecular ions. Due to their tendency to fragment rapidly, the intensity of the molecular ion peak in the mass spectrum is weak or sometimes absent. The fragmentation patterns for alcohols occur in two ways, i.e. &#9082;-cleavage and dehydration. During &#9082;-cleavage, the bond at the &#9082;-position adjacent to the hydroxyl group cleaves to give a resonance-stabilized cation and a radical. However, intramolecular dehydration involves losing a water molecule from an alcohol, forming an alkene cation, which shows a peak at M&#8722;18. Consider the fragmentation of butanol as shown below. &#9082;-cleavage produces a base peak at a mass-to-charge ratio of 31. In the case of dehydration, the fragmentation forms an alkene radical cation at a mass-to-charge ratio of 56.
<img alt="Figure1" src="/files/ftp_upload/13046/13046-PT_Figure_1.svg" style="text-align: center; height: 175px;" />

Alcohols (R-OH) ionize to lose one non-bonded electron from the oxygen atom, forming molecular ions. Due to their tendency to fragment rapidly, the ...

Mass Spectrometry: Amine Fragmentation

Amines can be identified using mass spectroscopy based on their characteristic fragmentation patterns. The molecular ions of amines undergo fragmentation via &#9082;-cleavage. The &#9082;-cleavage of the carbon-carbon bonds in amines generates an alkyl radical and resonance-stabilized nitrogen-containing cation.
In amines, the number of nitrogen atoms affects the mass of the molecular ion, which is described by the nitrogen rule of mass spectrometry. This rule states that a compound containing a single or an odd number of nitrogen atoms produces a molecular ion with an odd molecular weight, while a compound with no or an even number of nitrogen atoms generates a molecular ion with an even molecular weight.
For example, the mass spectrum of 3-methyl-1-butanamine, which contains one nitrogen atom, displays a molecular ion having an odd mass-to-charge ratio of 87. Fragmentation of this molecular ion via &#9082;-cleavage produces a base peak, which features a mass signal at a mass-to-charge ratio of 30, corresponding with the loss of the 2-methyl propyl radical.
Similarly, the fragmentation of triethylamine via &#9082;-cleavage generates a cation at a mass-to-charge ratio of 86. The molecular ion peak shows an odd mass-to-charge ratio of 101, as shown below.
<img alt="Figure1" src="/files/ftp_upload/13048/13048_PT_Figure_1.svg" style="text-align: center; height: 105px;" />

Amines can be identified using mass spectroscopy based on their characteristic fragmentation patterns. The molecular ions of amines undergo fragmentation ...

Mass Spectrometry: Cycloalkene Fragmentation

The molecular ions of cycloalkenes undergo fragmentation via a retro-Diels&#8211;Alder reaction.

The reaction proceeds via the cleavage of two carbon-carbon bonds in the cycloalkene to yield ethene. The remaining part of the cycloalkene structure is a dienyl radical cation with a molecular weight of 28 u lower than the molecular ion. This fragmentation pathway is similar to the fragmentation of cycloalkanes releasing ethene, differing only in the resultant radical cation. An alkyl species forms from the cycloalkane, whereas a dienyl species originates from the cycloalkene.

Retro-Diels&#8211;Alder reactions of cycloalkenes are also similar to the McLafferty-rearrangement-type fragmentation observed in acyclic alkenes with hydrogen on the &#947; carbon. In both cases, cleavage occurs at two positions, yielding an ethene molecule and an alkenyl species. In acyclic alkenes, the cleavage occurs at one carbon-carbon bond and a carbon-hydrogen bond, along with rearranging hydrogen from one carbon to another. In cyclic alkenes, cleavage occurs at two carbon&#8211;carbon bonds without any atomic rearrangement. Figure 1 depicts the fragmentation of cyclohexene via a retro-Diels&#8211;Alder reaction.
<img alt="Figure1" src="/files/ftp_upload/13044/13044-PT_Figure_1.svg" style="text-align: center; height: 90px;" />
Figure 1: Fragmentation of cyclohexene via a retro-Diels&#8211;Alder reaction.
In addition to the retro-Diels&#8211;Alder reaction, branched cycloalkenes exhibit fragmentation via cleavage of the side chain to form a cycloalkene cation. For example, the fragmentation of 1-methyl-1-cyclohexene via a retro-Diels&#8211;Alder reaction and side-chain cleavage are shown in Figure 2.
<img alt="Figure2" src="/files/ftp_upload/13044/13044-PT_Figure_2.svg" style="text-align: center; height: 225px;" />
Figure 2: Fragmentation of 1-methyl-1-cyclohexene via (top) a retro-Diels&#8211;Alder reaction; (bottom) side-chain cleavage.
The corresponding signals of the isoprenyl radical cation and the cyclohexenyl cation are evident in the mass spectrum of 1-methyl-1-cyclohexene shown in Figure 3.
<img alt="Figure3" src="/files/ftp_upload/13044/13044-PT_Figure_3.svg" style="text-align: center; height: 250px;" />
Figure 3: Mass spectrum of 1-methyl-1-cyclohexene.

The molecular ions of cycloalkenes undergo fragmentation via a retro-Diels&#8211;Alder reaction.

The reaction proceeds via the cleavage of two ...

Mass Spectrometry: Alkyne Fragmentation

The fragmentation of alkynes preferentially occurs at the carbon&#8211;carbon bond between the &#945; and &#946; carbon of the alkyne bond to generate a 3-propynyl cation (or propargyl cation). In terminal alkynes, there is the only type of fragmentation that yields the 3-propynyl cation. The unsubstituted 3-propynyl cation exhibits a peak at a mass-to-charge ratio of 39. In internal alkynes, the 3-propynyl cation is substituted. For example, 2-pentyne fragments into methyl-substituted 3-propynyl cation, which subsequently features as a mass signal at the mass-to-charge ratio of 56. The 3-propynyl cation is resonance-stabilized, and the corresponding mass signal is intense in the mass spectrum of alkynes. Figure 1 shows the fragmentation of 1-pentyne into an ethyl radical and a resonance stabilized 3-propynyl cation.
<img alt="Figure1" src="/files/ftp_upload/13045/13045-PT_Figure_1.svg" style="text-align: center; height: 115px;" />
Figure 1: Fragmentation of 1-pentyne molecular ion to yield the 3-propynyl cation.
Another fragmentation pathway observed in terminal alkynes is the loss of hydrogen from the terminal sp carbon. This results in a mass signal with a mass-to-charge ratio of one unit less than the molecular ion. This M&#8211;1 peak is very intense and becomes the base peak in the mass spectra of many alkynes, so it can be used to identify alkynes.
<img alt="Figure2" src="/files/ftp_upload/13045/13045-PT_Figure_2.svg" style="text-align: center; height: 275px;" />
Figure 2: The mass spectrum of 1-pentyne.

The fragmentation of alkynes preferentially occurs at the carbon&#8211;carbon bond between the &#945; and &#946; carbon of the alkyne bond to generate a ...

Mass Spectrometry: Branched Alkane Fragmentation

This lesson delves into the mass spectrometry of branched alkane fragmentation. Branched alkanes possess secondary or tertiary carbon atoms, which generate relatively stable carbocations if the cleavage occurs at the branching point. The high stability of carbocations drives the instant fragmentation of branched alkanes. Accordingly, the branched alkane&#39;s molecular ion peak is very weak or invisible in the mass spectra, especially in comparison to a linear alkane.
<img alt="Figure1" src="/files/ftp_upload/13041/13041-PT_Figure_1.svg" style="text-align: center; height: 275px;" />
Figure 1. Fragmentation pathway of 2-methylbutane (top), neopentane (middle), and n-pentane (bottom) molecular ions.
Figure 1 shows the most feasible fragmentation pathway observed in 2-methyl butane, neopentane, and n-pentane molecular ions. 2-methyl butane and neopentane fragment to yield secondary and tertiary carbocations, respectively. The stability of these carbocations drives the fragmentation reaction, even though the co-produced methyl radical is relatively unstable. In contrast, the cleavage of n-pentane leading to the methyl radical is difficult since the stability of a primary carbocation is low.
<img alt="Figure2" src="/files/ftp_upload/13041/13041-PT_Figure_2.svg" style="text-align: center; height: 105px;" />
Figure 2. Fragmentation of 2,2-dimethylpentane.
As shown in Figure 2, the fragmentation of 2,2-dimethyl pentane involves the loss of either methyl or propyl radical, resulting in a tertiary carbocation. Here, the stability of the co-produced radical determines the cleaving bond. So, the cleavage that produces a propyl radical is favored, and the signal from the 2-methyl propyl carbocation becomes the base peak.

This lesson delves into the mass spectrometry of branched alkane fragmentation. Branched alkanes possess secondary or tertiary carbon atoms, which ...

Using Point of Care Ultrasound to Augment Acquisition of Physical Exam Skills: Organs

Source: Joseph H. Donroe, Rachel Liu; Yale School of Medicine, USA
Point of care ultrasound (POCUS) is used by clinicians for diagnosis, ongoing monitoring, and/or procedural guidance at the time of patient care. Many medical schools are now teaching POCUS as a part of their basic clinical skills training, in addition to history, physical exams, and clinical reasoning. Besides being an independent skill, POCUS is also an incredibly useful tool for augmenting the teaching and learning of the physical exam.
Learning the physical exam involves combining the knowledge of anatomy and physiology with the technical skills of performing maneuvers. This can be especially difficult when learning the physical exam on a healthy subject, where certain exam findings can be difficult to appreciate by palpation or percussion. Ultrasound is an imaging modality that can highlight anatomy and physiology in real-time and, when performed in conjunction with the physical exam, can lead to the improved acquisition of exam skills.
Examination of the cardiovascular system, lungs, abdomen, and thyroid can be a challenging skill for trainees to acquire, but an ultrasound can help to simplify the learning. With ultrasound, we can visualize the closing of heart valves and the timing of systole and diastole, thus adding visual clues to auscultation. Palpation of certain body parts, such as the popliteal and abdominal aorta, thyroid, liver edge, gall bladder, and spleen, are commonly met with uncertainty by learners. These body parts are easily visible using ultrasound, allowing learners to confirm hand placement and verify findings. Measurements of diaphragmatic excursion and liver span by percussion can also be confirmed under ultrasound, thus providing a standard for improving percussion technique. Finally, visualization of the internal jugular vein using ultrasound can improve inspection for jugular venous distension.
Studies have demonstrated that ultrasound training improves elements of the cardiac, pulmonary, abdominal, musculoskeletal, and vascular exams. Additionally, integrating ultrasound teaching with other clinical skills results in high student satisfaction and improved confidence in performing the physical exam. In this video, we will demonstrate how to use POCUS to facilitate learning the examination of the thyroid, lung, heart, liver, and spleen in a healthy subject.

Usando ultrassom no local de atendimento para aumentar a aquisição de habilidades de exame físico: órgãos

Source: Joseph H. Donroe, Rachel Liu; Yale School of Medicine, USA
Point of care ultrasound (POCUS) is used by clinicians for diagnosis, ongoing ...

Using Point of Care Ultrasound to Augment Acquisition of Physical Exam Skills: Knee and Shoulder

Source: Joseph H. Donroe, Rachel Liu; Yale School of Medicine, USA
Point of Care Ultrasound or POCUS is easy to use, has enhanced mobility due to the smaller equipment needed, and may be carried out in a variety of settings. It is also far safer and cheaper than imaging techniques like computer tomography.
POCUS can be helpful when certain physical exam findings are difficult to appreciate by palpation, percussion, or auscultation and can facilitate learning elements of the cardiac, pulmonary, abdominal, musculoskeletal, and vascular exams.
With ultrasound, the anatomy of the knee and shoulder are easily visualized, thus allowing a better understanding of the anatomic basis for many exam maneuvers.&#160; Ultrasound allows for the detection of tendons, ligaments, and muscle injury, the presence of fluid, structural abnormalities, and bone fractures in the musculoskeletal region.
In the case of the knee, ultrasound is helpful in the detection of injuries of the quadriceps and patellar tendons; injuries of the medial and lateral collateral ligaments; meniscal tears; effusions; degenerative changes; bursitis of the suprapatellar, prepatellar, infrapatellar, and pes anserine bursae; and other similar diseases. On the other hand, in the shoulder, ultrasound can be useful in the diagnosis of rotator cuff disease, biceps brachii injury, and acromioclavicular joint disease, among other shoulder pathologies.
Ultrasound is also a dynamic imaging modality that can highlight the movement of joints and muscles in real-time. Therefore, it can lead to the improved acquisition of exam skills when performed in conjunction with the specific maneuvers. For example, shoulder impingement syndrome can be better understood by learners of the physical exam by seeing the anatomy and dynamic movements under ultrasound.
Examination of the musculoskeletal system is a particularly difficult skill to acquire, involving the integration of the technical skills to perform specific maneuvers with the relevant clinical anatomy and physiology of joints. Overall, the integration of ultrasound with other clinical skills results in improved confidence and accuracy in the performance of the physical exam. In this video, we will demonstrate how to use POCUS to facilitate learning the examination of the knee and shoulder.

Usando ultrassom no local de atendimento para aumentar a aquisição de habilidades de exame físico: joelho e ombro

Source: Joseph H. Donroe, Rachel Liu; Yale School of Medicine, USA
Point of Care Ultrasound or POCUS is easy to use, has enhanced mobility due to the ...

Using Point of Care Ultrasound to Augment Acquisition of Physical Exam Skills: Veins and Arteries

Source: Joseph H. Donroe, Rachel Liu; Yale School of Medicine, USA
Vascular diseases make up most cases of emergency hospitalization and carry a high mortality risk. Point-of-care ultrasound or POCUS enables accurate diagnosis of these diseases and shortens the time between detection of the cause and selection of appropriate treatment strategies, thus, reducing the patient mortality rate. POCUS offers a safe, low-cost, and less invasive bedside tool for examining arteries and veins, besides its many other applications.
For learners, the anatomical difference between arteries and veins can also be better understood with the help of POCUS. Arteries are thicker walled and pulsatile; veins are thinner walled, may have valves, and collapse when compressed.
Arteries may be difficult to palpate if they are deeper, have reduced blood flow, or a practitioner does not know the anatomic landmarks or is inexperienced. During an examination, while palpation enables an understanding of the intensity, symmetry, and rhythm of blood flow, POCUS can provide exact information on the underlying anatomy and location of the blood vessels. For example, the dorsalis pedis is a major artery that runs over the dorsal foot. It can become impalpable if the flow is obstructed. In such a condition, POCUS can help to detect the absence of blood flow.&#160;
Consider the internal jugular vein or IJV, which drains venous blood from the brain and superficial veins of the face and finally delivers the blood to the right atrium of the heart. Visualization of the internal jugular vein under ultrasound can improve inspection for jugular venous distension.
Among the arteries, the aorta is the main artery that carries oxygenated blood from the heart and branches off to deliver blood to the rest of the body. The portion of the aorta that passes through the abdomen, from the diaphragm to the umbilical area, is known as the abdominal aorta. The abdominal aorta is examined using POCUS to diagnose life-threatening conditions such as abdominal aortic aneurysm&#8212; a swelling in the aorta, or aortic dissection&#8212; a tear in the artery.&#160;
The conceptual knowledge of the vascular system combined with the technical skills of using palpation and ultrasound can help make life-saving diagnoses during physical examination.
In this video, we will demonstrate how to use POCUS to facilitate learning the examination of veins and arteries.

Usando ultrassom no local de atendimento para aumentar a aquisição de habilidades de exame físico: veias e artérias

Source: Joseph H. Donroe, Rachel Liu; Yale School of Medicine, USA
Vascular diseases make up most cases of emergency hospitalization and carry a high ...

Accessibility to Clinical Care for People who use Wheelchairs

Source: Yetsa Tuakli-Wosornu1,2, Jaideep Talwalkar1; 1Yale School of Medicine, 2University of Pittsburgh
In the United States, 25% of the general population suffers from one or another type of disability. Ambulatory disabilities, or mobility impairments, represent the most common subcategory, comprising 14% of the country&#39;s populace. Different mobility-assistive devices, ranging from canes to scooters, enable increased independence and improved quality of life for those suffering from mobility impairment. Wheelchairs or wheeled mobility devices are the most important among these, and an estimated 2.7 million people in the US use manual and powered wheelchairs annually. In the future, these numbers will increase due to rising chronic health conditions and an aging population. People who use wheelchairs often experience barriers to medical services in healthcare settings due to generalized disability stigma, inaccessible medical settings, inadequately trained clinic staff, and the inability of healthcare providers to understand all of their patients&#39; needs.
Section 504 of the 1973 Rehabilitation Act and the 1990 Americans with Disabilities Act (ADA) are federal civil rights legislations that protect US citizens with disabilities from discrimination, and mandate appropriate accommodation(s) be provided to ensure equal access, opportunities, and care in all sectors of society, including healthcare. Those with mobility impairment who use wheelchairs are therefore protected under law, and must be afforded equal access to clinical care for the prevention and treatment of illness, injury, and disease. Despite the laws, many clinical settings still struggle to provide such an inclusive environment. The US Department of Justice and Department of Health and Human Services&#39; Access to Medical Care for Individuals with Mobility Disabilities summarizes practical strategies that healthcare settings should adopt to create an accessible, ADA-compliant clinical environment. Reviewing and implementing these and other strategies are essential if clinical practices are to offer people who use wheelchairs the same level of care as those who do not.
Most details related to the medical care for people who use wheelchairs are no different than for people without a disability. Such elements of the physical examination will not be reviewed in this video in order to emphasize points where care is often lacking or must be approached differently. Given the prevalence of mobility impairment, the protocol described below should be a standard practice in medical settings, rather than an exception in specially designed office spaces.

Acessibilidade ao Atendimento Clínico para Pessoas que usam Cadeira de Rodas

Source: Yetsa Tuakli-Wosornu1,2, Jaideep Talwalkar1; 1Yale School of Medicine, 2University of Pittsburgh
In the United States, 25% of the general ...

Physical Exam Considerations for People who use Wheelchairs

Source: Yetsa Tuakli-Wosornu1,2, Jaideep Talwalkar1; 1Yale School of Medicine, 2University of Pittsburgh
In addition to the regular checks of a physical exam, examinations for patients who use wheelchairs should be adapted to address their specific needs. This ensures that the patient&#39;s mobility, injury risk, and quality of life are not threatened by extended periods of sitting, potentially without proper weight shifts. Such examination needs healthcare providers that understand these requirements, easily accessible medical equipment, and staff who are adequately trained to operate the equipment. For example, people with mobility disabilities are at risk of developing pressure sores. Prolonged sitting on the wheelchair causes increased temperature and moisture in areas of contact with the wheelchair surface. Such injuries are localized areas of skin and soft tissue damage and are common in the occiput, sacrum, and ischial tuberosity of the patient.
If the patient uses a manual wheelchair, bony prominences like elbows and greater trochanters may show abrasions, erythema, and ulcerations. The correct fit in the wheelchair is also important for the patient&#39;s comfort, to improve mobility and overall health. While checking for a wheelchair fit, the seat width, depth, and height must be determined to ensure that the patient can sit comfortably in it. Similarly, the armrests, footrest, and backrest height must be decided according to the user&#39;s needs. For example, patients with difficulty in sitting upright need a higher backrest. In comparison, a backrest with free movement of the shoulders is required for patients who push the wheelchair themselves.
Additionally, a patient&#39;s weight can be an important indicator of the patient&#39;s health. A wheelchair scale must be used to weigh patients in a wheelchair who are unable to stand on their own. This measurement must also be taken into consideration because wheelchairs are meant to accommodate a certain weight, which can affect comfort, fit, and overall patient well-being. A new wheelchair or seating adjustment may be required when the patient&#39;s posture seems to lead to deformities, pain, or skin abrasions. For example, pain in the shoulder is indicative of a wrong posture while using a manual wheelchair. Overall, most details related to the medical care for people who use wheelchairs are no different than the care provided to every other person. In this video, we will demonstrate how to measure weight, and what specific clinical considerations to take into account while performing a physical examination on a patient who uses a wheelchair.&#160;

Considerações sobre o exame físico para pessoas que usam cadeiras de rodas

Source: Yetsa Tuakli-Wosornu1,2, Jaideep Talwalkar1; 1Yale School of Medicine, 2University of Pittsburgh
In addition to the regular checks of a physical ...

Mental Status Examination

Source:&#160;Carmen Black, Matthew Goldenberg, and Jaideep Talwalkar;&#160;Yale School of Medicine
The mental status exam is a clinical evaluation of emotional, perceptual, and cognitive functioning that spans both the fields of psychiatry and neurology. Developing skill in the psychiatric portions of the examination are important to describe salient aspects of the patient&#39;s mental state that may be observed during routine history and/or physical exam. Proficiency in the cognitive portions of this evaluation is vital while caring for patients with suspected cognitive impairment from illnesses like dementia, delirium, and substance intoxication. This video will teach students how to assess both cognitive and psychiatric portions of this examination, including behavior, speech, mood, affect, thought process and content, perception, attention, orientation, registration, and executive function.
The mental status exam is unique in that a variety of non-clinical factors may differentially impact how a patient performs while undergoing this exam in English. Furthermore, the mental status examination differs from other forms of physical examination as it requires a combination of directed questions and passive observation. Due to its reliance upon clinicians&#39; perception and passive observation of diverse patient populations, proper execution and cultural validity of the exam are facilitated by an awareness of how several sociocultural factors may differentially impact patient presentation and clinician interpretation. Additionally, examiners often rely upon tests of verbal fluency and math skills to evaluate cognitive function. However, it is important for examiners to be sensitive to the needs of the patients with a wide diversity of languages and education levels. Therefore, this video will also address how to equitably administer the examination for patients from various socioeconomic, educational, and cultural backgrounds.

Exame do estado mental

Source:&#160;Carmen Black, Matthew Goldenberg, and Jaideep Talwalkar;&#160;Yale School of Medicine
The mental status exam is a clinical evaluation of ...

The Comprehensive Infant Examination

Source: Heather Collette&#160;and Jaideep Talwalkar; Yale School of Medicine
The newborn exam is important in establishing a baby&#39;s baseline health status as they enter the world. Newborn providers have the unique opportunity to evaluate a patient for the very first time. They are also tasked with identifying congenital anomalies that require early intervention to promote a long and healthy life for the child. Many newborn anomalies, such as heart defects, are noted on prenatal ultrasound. However, some anomalies are not apparent until the baby is born. A systematic approach ensures a complete newborn exam so that anomalies are not missed.&#160;
If the baby is stable after birth, it is recommended to wait to examine them until they have spent at least 1 hour of skin-to-skin time with their mother. This regulates the baby&#39;s heart rate and breathing, promotes bonding, and establishes breastfeeding.

O exame completo do recém-nascido

Source: Heather Collette&#160;and Jaideep Talwalkar; Yale School of Medicine
The newborn exam is important in establishing a baby&#39;s baseline health ...

Toddler and Preschool Child Exam

Source: Heather Collette&#160;and Jaideep Talwalkar; Yale School of Medicine
The key to a successful exam of a toddler or preschool-age child is building rapport and trust between them and the provider. Toddlers, in particular, may be wary of strangers and unwilling to cooperate with the physical exam, which is expected age-appropriate behavior. In order to provide good care and create a comfortable patient experience, clinicians need to tailor their interaction to the child&#39;s developmental stage. Ensuring positive medical encounters for children will increase their likelihood of seeking medical care as they age into adulthood. Clinicians must be creative and flexible as they work with children to achieve their care goals. Suggestions on how to facilitate these interactions will be covered in this video, with less of a focus on specific organ system components, as these are similar to other age groups.
Toddlerhood through preschool age is a time of significant physical and developmental growth. Progression of language, motor, and social skills is a reflection of children&#39;s brain growth and social environment. Normal development follows a typical progression, but exact time points for achieving developmental milestones can vary among children. Achieving a specific milestone a few months later than another child or based on a time point listed on a development chart does not necessarily indicate a problem. Providers must ensure that children meet developmental milestones as expected and, if not, refer them early for special services to promote the best outcome possible.&#160;

Exame para bebês e crianças em idade pré-escolar

Source: Heather Collette&#160;and Jaideep Talwalkar; Yale School of Medicine
The key to a successful exam of a toddler or preschool-age child is building ...

Adolescent Exam

Source: Heather Collette&#160;and Jaideep Talwalkar; Yale School of Medicine&#160;
The adolescent module will focus on techniques to promote a trusting provider-patient relationship and foster healthcare autonomy as teenagers approach adulthood. While most of the basic components of the physical exam in adolescents are similar to those in adults, there is added focus on pubertal development through the use of the Sexual Maturity Rating scale. Discussion of physical changes is accompanied by important adolescent psychosocial screening questions, including environmental safety, mental health, sexual activity, and drug/alcohol use.&#160;
Adolescence is a time of significant physical changes as surges of hormones, such as estrogen and testosterone, cause growth in stature and the development of secondary sexual characteristics. These secondary characteristics at puberty include new hair growth, breast, and penile maturation that happen in a predictable series.
Adolescence is also a time of marked physical and emotional changes, which can be distressing and uncomfortable for adolescents. Pediatric providers can play a key role in relieving some distress by normalizing feelings and physical changes. To build a trusting provider-patient relationship, the provider needs to create an environment where the adolescent feels safe to disclose personal information and concerns. Adolescents should be treated as unique individuals, respectfully and without preconceived notions about their concerns or goals.
An eventual goal in the care of adolescents is to prepare them for navigating their health and healthcare as adults. The transfer to an adult-oriented care system typically occurs sometime after age 18, though the transition process for a successful transfer starts years before that.

Exame do Adolescente

Source: Heather Collette&#160;and Jaideep Talwalkar; Yale School of Medicine&#160;
The adolescent module will focus on techniques to promote a trusting ...

The 4 M&#8217;s Framework: Case History and Physical Examination of Older Adults

Source:&#160;Jennifer A. Ouellet and Jaideep Talwalkar; Yale School of Medicine
To meet the needs of older adults, all health professionals should be well acquainted with the history and physical examination considerations unique to this population. Physical examination plays an important role in the older patient to detect physiologic changes of aging, risk factors, and signs of pathology. While most of the general principles of the standard examination for adults apply to older patients, there are additional specific considerations. For example, focused examinations of cognitive and functional status are critical, as are assessments of hearing, vision, nutritional status, and the nervous system. This video will provide an overview of key aspects of the physical examination in older adults, including the use of standardized tools such as the 4 M&#39;s, the Timed&#160;Get Up and Go, and the Mini-Cog.

The 4 M&amp;#8217;s Framework: Case History and Physical Examination of Older Adults

Estrutura dos 4 Ms: Histórico do Caso e Exame Físico de Idosos

Source:&#160;Jennifer A. Ouellet and Jaideep Talwalkar; Yale School of Medicine
To meet the needs of older adults, all health professionals should be well ...

Education Physical Examinations Iv

Science Education (Habilidades Clínicas)

Science Education (Habilidades Clínicas)

Science Education (Habilidades Clínicas)

Science Education (Habilidades Clínicas)

Science Education (Habilidades Clínicas)

Science Education (Habilidades Clínicas)

Science Education (Habilidades Clínicas)

Science Education (Habilidades Clínicas)

Science Education (Habilidades Clínicas)

Science Education (Habilidades Clínicas)

Education Physical Examinations Iv

@media screen and (min-width: 320px){.css-u03n47{font-size:var(--chakra-fontSizes-xs);}}Science Education (Habilidades Clínicas)

Science Education (Habilidades Clínicas)

Science Education (Habilidades Clínicas)

Science Education (Habilidades Clínicas)

Science Education (Habilidades Clínicas)

Science Education (Habilidades Clínicas)

Science Education (Habilidades Clínicas)

Science Education (Habilidades Clínicas)

Science Education (Habilidades Clínicas)

Science Education (Habilidades Clínicas)

Science Education (Habilidades Clínicas)