cv and respiratory history &physical exam review family medicine fellows

CV and Respiratory History &Physical ExamReview

Family Medicine Fellows

Overview CV Exam

History Inspection Palpation Auscultation

Lung Exam History Inspection Palpation Percussion Auscultation

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

Cardiovascular Exam

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

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

Inspection Look for

Chest deformities/trauma

Obvious pulsations Where could there be

pulsations? Apex Major arteries

What is normal? None of the above

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

Osteopathic Considerations Osteopathic diagnostics:

Sympathetic Scan upper thoracics T1-T5 (heart)

Parasympathetic Scan upper cervicals Right and left vagus

Auscultation Components

Rate and Rhythm Normal sounds: S1, S2 Splitting of sounds Abnormal sounds:

Gallops: S3, S4 Murmurs Friction rubs

Where to listen?

Ausculation: Rate and Rhythm Rate How do we describe rhythm?

Regular Irregular

Regularly irregular Irregularly irregular

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)

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

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

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

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.”

Examples of Murmurs Mitral

Stenosis Regurgitation

Aortic Stenosis Regurgitation

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

Further characterizing Sounds

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

Peripheral vascular exam

Inspection: Jugular Venous Pressure

Demonstration-http://meded.ucsd.edu/clinicalmed/cvp_movie.htm

Inspection

Skin color Skin temperature

(warm/cold) Skin lesions

Ulcers Embolism (black toes,

splinter hemorrhage) Petechiae or purpura Xanthoma/xanthelasma

Edema Varicosities

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

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

Radial Artery

Femoral Artery

Popliteal Artery

Dorsalis Pedis Artery

Grading Edema

Bruits: Vascular Turbulence Ask patient to hold

breath for a moment Listen with

diaphragm Possible Locations

Carotid Temporal Abdominal aorta Renal Iliac Femoral

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

Lung Exam

Surface Anatomy

Surface Anatomy

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

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

Osteopathic Considerations Costal cage: screen and scan Lymphatic

Movement of diaphragm and respiratory rate/depth

Sympathetic T1-T6 (lungs)

Parasympathetic Right and left vagus

Chest Deformities

Pectus Excavatum Pectus Carinatum

Barrel Chest

Clubbing

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)

Rib excursion/Tactile fremitus

Percussion Why do we

percuss the lungs? To determine

composition of underlying tissues Air, fluid, solid Quick strike using

relaxed wrist motion

Auscultation Normal sounds:

loudness Vesicular- I > E Bronchovesicular- I =

E Bronchial- E > I Tracheal- I = E

Only normal if heard in the right place!

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

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

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

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