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CV and Respiratory History &Physical Exam Review Family Medicine Fellows.

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Presentation on theme: "CV and Respiratory History &Physical Exam Review Family Medicine Fellows."— Presentation transcript:

1 CV and Respiratory History &Physical Exam Review Family Medicine Fellows

2 Overview  CV Exam  History  Inspection  Palpation  Auscultation  Lung Exam  History  Inspection  Palpation  Percussion  Auscultation

3 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

4 Cardiovascular Exam

5 CV Phys 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

6 Components to Assess in CV Exam Heart  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

7 Inspection  Look for  Chest deformities/trauma  Obvious pulsations  Where could there be pulsations?  Apex  Major arteries  What is normal?  None of the above

8 Palpation  Palpate: Point of Maximal Impulse  What’s normal?  NORMALLY: Located in the 4 th or 5 th 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

9 Osteopathic Considerations  Osteopathic diagnostics:  Sympathetic  Scan upper thoracics  T1-T5 (heart)  Parasympathetic  Scan upper cervicals  Right and left vagus

10 Auscultation  Components  Rate and Rhythm  Normal sounds: S1, S2  Splitting of sounds  Abnormal sounds:  Gallops: S3, S4  Murmurs  Friction rubs

11 Where to listen?

12 Ausculation: Rate and Rhythm  Rate  How do we describe rhythm?  Regular  Irregular  Regularly irregular  Irregularly irregular

13 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)

14 Physiologic Splitting  What is physiologic splitting?  Normal gap between valve closures  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

15 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

16 Murmurs  Timing  Shape  Location of max intensity  Radiation  Pitch  Quality Find answers to these murmurs at:

17 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.”

18 Examples of Murmurs  Mitral  Stenosis Stenosis  Regurgitation Regurgitation  Aortic  Stenosis Stenosis  Regurgitation Regurgitation

19 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

20 Further characterizing Sounds

21 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

22 Peripheral vascular exam

23 Inspection: Jugular Venous Pressure Demonstration- ed/cvp_movie.htm

24 Inspection  Skin color  Skin temperature (warm/cold)  Skin lesions  Ulcers  Embolism (black toes, splinter hemorrhage)  Petechiae or purpura  Xanthoma/xanthelasma  Edema  Varicosities

25 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

26 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

27 Radial Artery

28 Femoral Artery

29 Popliteal Artery

30 Dorsalis Pedis Artery

31 Grading Edema

32 Bruits: Vascular Turbulence  Ask patient to hold breath for a moment  Listen with diaphragm  Possible Locations  Carotid  Temporal  Abdominal aorta  Renal  Iliac  Femoral

33 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

34 Lung Exam

35 Surface Anatomy

36

37 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

38 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

39 Osteopathic Considerations  Costal cage: screen and scan  Lymphatic  Movement of diaphragm and respiratory rate/depth  Sympathetic  T1-T6 (lungs)  Parasympathetic  Right and left vagus

40 Chest Deformities Pectus Excavatum Pectus Carinatum

41 Barrel Chest

42 Clubbing

43 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)

44 Rib excursion/Tactile fremitus

45 Percussion  Why do we percuss the lungs?  To determine composition of underlying tissues  Air, fluid, solid  Quick strike using relaxed wrist motion

46 Auscultation  Normal sounds: loudness  Vesicular- I > E  Bronchovesicular- I = E  Bronchial- E > I  Tracheal- I = E  Only normal if heard in the right place!

47 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

48 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

49 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

50 Resources    Bates 8 th edition  12/14/09 OMM lecture  Auscultation assistant:  Taber’s Cyclopedic Medical Dictionary, 20 th edition


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