cv and respiratory history &physical exam review family medicine fellows
TRANSCRIPT
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CV and Respiratory History &Physical ExamReview
Family Medicine Fellows
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Overview CV Exam
History Inspection Palpation Auscultation
Lung Exam History Inspection Palpation Percussion Auscultation
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Subjective-Review Chief Complaint History of the present
illness Past medical history Injuries/immunizations Medications Allergies Surgeries Hospitalizations
Family history Social history
Diet Exercise Smoking Caffeine Alcohol Nicotine Marrital Status Occupation
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Cardiovascular Exam
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CV Phys 101
1. Inferior vena cava
2. Superior vena cava
3. Right atrium
4. Tricuspid valve
5. Right ventricle
6. Pulmonic valve
7. Pulmonic branch
8. Pulmonary arteries
9. Pulmonary veins
10. Left atrium
11. Mitral valve
12. Left ventricle
13. Aortic valve
14. Aorta
15. Brachiocephalic artery
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Components to Assess in CV ExamHeart Inspection: Obvious
pulsations Palpation: Point
Maximal Impulse (PMI) Auscultate:
Normal sounds Abnormal sounds:
Murmurs Rubs Gallops
Peripheral vascular system
Inspection: JVP, varicosities, skin changes
Palpation: Peripheral pulses, extremities
Auscultation: bruits
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Inspection Look for
Chest deformities/trauma
Obvious pulsations Where could there be
pulsations? Apex Major arteries
What is normal? None of the above
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Palpation Palpate: Point of Maximal Impulse
What’s normal? NORMALLY: Located in the 4th or 5th intercostal space at
the midclavicular line Identify a Heave or Lift
Sustained, systolic outward movement of the precordium, associated with heart failure
Palpate: Thrills Vibration (like a cat purring) What’s normal? NORMALLY: none found
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Osteopathic Considerations Osteopathic diagnostics:
Sympathetic Scan upper thoracics T1-T5 (heart)
Parasympathetic Scan upper cervicals Right and left vagus
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Auscultation Components
Rate and Rhythm Normal sounds: S1, S2 Splitting of sounds Abnormal sounds:
Gallops: S3, S4 Murmurs Friction rubs
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Where to listen?
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Ausculation: Rate and Rhythm Rate How do we describe rhythm?
Regular Irregular
Regularly irregular Irregularly irregular
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Heart Sounds (Normal) What are normal
sounds? What is S1?
Mitral and tricuspid valve closure
What is S2? Aortic and pulmonic
valve closure How do we tell the
difference?
(Mitral)
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Physiologic Splitting
What is physiologic splitting? Normal gap between valveclosures
Do both S1 and S2 split? Only S2 is audible Aortic valve (A2) closes first Pulmonic valve (P2) closes second
Splitting is accentuated by? Deep inspiration
Is there non-physiologic splitting? Yes it can be associated with pathology
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Abnormal Sounds: Gallops S3: Created by blood from the
left atrium slamming into an already overfilled ventricle during diastole
S4: Created by blood trying to enter a stiff ventricle during atrial contraction
Both are low-pitched “extra sounds” heard best with the bell of your stethoscope
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Murmurs Timing Shape Location of max
intensity Radiation Pitch Quality
Find answers to these murmurs at: http://www.wrongdiagnosis.com/symptoms/rapid_heart_beat/book-causes-5a.htm
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Murmurs Grading conveys intensity Systolic:
I – faint, barely audible II – quiet, but can be heard immediately III – moderately loud IV – quite loud; associated with a thrill V – loud enough to be heard with the stethoscope not completely in
contact with the chest wall; associated with a thrill VI – loud enough to be heard with the stethoscope close to but not
actually touching the chest; associated with a thrill
Diastolic: Grades I-IV
Putting it all together: “There is a medium/high-pitched, grade II/VI holosystolic blowing murmur heard best at the cardiac apex, with radiation to left axilla.”
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Examples of Murmurs Mitral
Stenosis Regurgitation
Aortic Stenosis Regurgitation
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Other Sounds Click
Abrupt and brief Snap
Sharp cracking sound; classic description of S1 in mitral stenosis
Rub Friction of one surface moving over another
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Further characterizing Sounds
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Practice Inspect
Obvious chest deformities
Obvious pulsations Palpate
PMI Thrills
Osteopathic Cervical, thoracic
scan
Auscultate Rate and rhythm Normal sounds: S1,
S2 Splitting of sounds Abnormal sounds:
Gallops: S3, S4 Murmurs Clicks, snaps, friction
rubs
Do these in a few different positions
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Peripheral vascular exam
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Inspection: Jugular Venous Pressure
Demonstration-http://meded.ucsd.edu/clinicalmed/cvp_movie.htm
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Inspection
Skin color Skin temperature
(warm/cold) Skin lesions
Ulcers Embolism (black toes,
splinter hemorrhage) Petechiae or purpura Xanthoma/xanthelasma
Edema Varicosities
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Osteopathic Considerations Lymphatic
Check for fascia restriction at choke points Lymphatic treatments
Sympathetic Vasoconstriction T2-T8 upper extremity T10-L2 lower extremity
No parasympathic involvement
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Palpation of PV system Capillary Refill
≤ 2 sec Pulses
Carotid Axillary Brachial Radial Femoral Popliteal Dorsalis pedis Posterior tibialis
Grading of Pulses 0-absent 1-diminished 2-normal 3-increased 4-bounding
Grade of Edema Pitting: Grade I-IV Non-Pitting
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Radial Artery
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Femoral Artery
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Popliteal Artery
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Dorsalis Pedis Artery
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Grading Edema
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Bruits: Vascular Turbulence Ask patient to hold
breath for a moment Listen with
diaphragm Possible Locations
Carotid Temporal Abdominal aorta Renal Iliac Femoral
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Practice!Peripheral vascular
system Inspection:
JVP Varicosities Skin lesions
Palpation Peripheral pulses Edema
Osteopathic Fascial restriction Scan
Auscultation: Carotid Temporal Abdominal aorta Renal Iliac Femoral
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Lung Exam
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Surface Anatomy
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Surface Anatomy
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Lung Exam Inspection of chest
Size Shape Symmetry Use of accessory
muscles Palpate
General osteopathic screen of thorax and costal cage
Tactile fremitus
Percussion Ausculate
Normal sounds: vesicular breathing
Abnormal sounds: Wheezes Rhochi Crackles Friction rubs
Vocal Resonance
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Inspection: Normal Deformities
Barrel chest Flail chest Pectus excavatum Pectus carinatum Kyphoscoliosis
Cyanosis Clubbing
Breathing Issues Acutely dyspneic Stridor
High-pitched, harsh sound that can indicate upper airway obstruction
Auditory wheezing Using accessory
muscles to breathe Clubbing Cyanosis Pattern of breathing
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Osteopathic Considerations Costal cage: screen and scan Lymphatic
Movement of diaphragm and respiratory rate/depth
Sympathetic T1-T6 (lungs)
Parasympathetic Right and left vagus
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Chest Deformities
Pectus Excavatum Pectus Carinatum
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Barrel Chest
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Clubbing
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Palpation: Trachea
How do you describe the normal trachea? Midline
Tactile fremitus Palpable vibrations while
patient speaks Use palms of hands or
ulnar side of hands “99” What is the normal result
of fremitus? Consistent throughout (no
increase or decrease)
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Rib excursion/Tactile fremitus
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Percussion Why do we
percuss the lungs? To determine
composition of underlying tissues Air, fluid, solid Quick strike using
relaxed wrist motion
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Auscultation Normal sounds:
loudness Vesicular- I > E Bronchovesicular- I =
E Bronchial- E > I Tracheal- I = E
Only normal if heard in the right place!
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Adventitious (added) Sounds Discontinuous
Fine crackles Course crackles
Continuous Wheezes
High pitched; musical Stridor
Rhonchi Sonorous
Description: Loudness Pitch Duration Timing Location
Bronchophony Increase in tone or clarity
in vocal resonance Egophony
E-to-A change
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Practice! Inspection of chest
Size Shape Symmetry Use of accessory
muscles Palpate
Tactile fremitus Osteopathic
Costal, thoracic screen scan
Percussion Ausculate
Normal sounds: vesicular breathing
Abnormal sounds: Wheezes Rhochi Crackles Friction rubs
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Final Practice CV Exam
Heart Inspect Palpate Look for PMI Auscultate Rate, rhythm, normal
and extra sounds Peripheral vascular
exam Include extremities and
pulses
Lung exam Inspect Look for respiratory
distress Palpate Percuss Auscultate
All Do osteopathic
screens
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Resources http://meded.ucsd.edu/clinicalmed/heart.htm http://meded.ucsd.edu/clinicalmed/lung.htm Bates 8th edition 12/14/09 OMM lecture Auscultation assistant: http://
www.med.ucla.edu/wilkes/intro.html Taber’s Cyclopedic Medical Dictionary, 20th
edition