History and Physical Examination You really only need to print the slides with the stars on them, to remind you how to perform each part of the examination.

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History and Physical Have the patient fill out a form that asks about their complete medical history. Take their vital signs Do a physical exam

Vital Signs Blood Pressure Heart Rate Respirations Temperature Height, Weight How to measure blood pressure (video)

Blood Pressure Use the right size cuff. Pediatric cuffs are available. So are extra large cuffs and extension wraps for larger patients. The patient should not smoke within 30 minutes of blood pressure reading The cuff should not be over clothing. It should touch the skin The patient’s arm should be supported at a 90 degree angle to the heart. The patient’s back should be supported against the back of their chair. The patient’s legs should not be crossed Wrap the cuff around the arm with the hoses ending at the inner surface of the decubital fossa (where blood is drawn). Place the diaphragm of the stethoscope on the decubital fossa, partly under the cuff edge. The cuff should not be over the elbow. It should be about 2cm above the elbow The patient should not be talking or engaged in active listening For wall-mounted gauges, observer should be at eye level with the gauge

Blood Pressure The patient’s arm should be straight at the elbow and held up at a 90 degree angle by the examiner so that the arm is at chest level. If the arm is too high or low, the readings are inaccurate! Turn the knob on the bulb to seal the air in. Pump until the gauge is over 200 mm Hg. Slowly turn the knob on the bulb the other way to release the air in the cuff and watch the gauge. Listen for the first heart sound and note the gauge reading. Continue listening for the last heart sound as it is barely audible and note the gauge reading. The two sounds are recorded. Normal is 120/80.

Arm should be at chest level Wrong Better

Arm should be at chest level Correct Correct arm angle, but she should be sitting

Find ten errors in this picture 1) Patient’s arm is unsupported; 2) Patient’s back is unsupported; 3) Patient is talking; 4) Patient is engaged in active listening; 5) Wrong size cuff in use 6) Blood pressure cuff is over the elbow; 7) Cuff is over clothing; 8) Observer is not at eye level with the wall-mounted gauge…where is the gauge? 9) Patient’s legs are crossed; 10) End of stethoscope is in clinician’s coat pocket. Find ten errors in this picture

Pulse Using two fingers (never the thumb, or you will be feeling your own pulse!), feel along the radius bone at the base of the patient’s thumb. Dig down a little on the medial side. Then keep your fingers on that part of the skin, but pull proximally a little. You should feel the pulse. Count how many beats there are for 15 seconds. Spend the next 15 seconds in this position, but ignore the pulse and count the number of breaths they take. If they know you are counting their breaths, they will not breathe normally. Multiply the heart rate (HR) and the respirations by four to get the number of heart beats per minute and the number of respirations per minute.

Stethoscope

Cardiac Auscultation Pediatric diaphragms and bells are available accessories for your stethoscope. The examination should be conducted in a warm, quiet room. Warm your hands and stethoscope Make sure the earpieces of the stethoscope face forward before putting them in your ears. Stand on the patient's right side Stethoscope diaphragm is pressed firmly on the chest, at four locations First sound is S1, second sound is S2 Repeat auscultation of the four sites with the bell placed lightly on the chest.

Cardiac Auscultation Sites

Abnormal Heart Sounds Friction rubs Gallops Murmurs http://www.wilkes.med.ucla.edu/intro.html

Rubs http://www.wilkes.med.ucla.edu/Rubintro.htm You are now listening to a typical example of a friction rub. It is caused by the beating of the heart against an inflamed pericardium or lung pleura, which itself has a wide variety of etiologies. This sound is usually continuous, and heard diffusely over the chest. It typically has three components, one systolic and two diastolic. The systolic occurs with ventricular contraction, and the diastolic occurs during both rapid ventricular filling and atrial contraction. It is accentuated when the patient sits up and leans forward, and may be accentuated during inspiration. If the rub completely disappears when the patient holds his breath it is more likely due to pleural, not pericardial, origin.

Gallops (S3 sounds) http://www.wilkes.med.ucla.edu/Rubintro.htm You are listening to a typical example of a third heart sound, or S3. Shortly after S2, the closing of the semilunar valves, the AV valves open and diastole begins. Diastole is itself further divided into several stages, the first being that of rapid filling, where 80% of the blood stored in the atria during systole is transferred to the ventricles. At the end of this stage, about 140-160 msec after S2, an S3 may be heard if the volume which has been transferred is abnormally large, as in mitral regurgitation. It can be thought of as a sound which is generated when the ventricle is forced to dilate beyond its normal range because the atrium has overloaded volume. An S3 is usually heard best with the bell of the stethoscope placed at the apex while the patient is in the left lateral decubitus position. The presence of an S3 is usually normal in children and young adults, but pathologic in those over the age of 40.

Murmurs http://www.wilkes.med.ucla.edu/Rubintro.htm You are listening to a typical example of a murmur caused by a patent ductus arteriosis. This vascular channel between the aorta and pulmonary artery remains open in a small percentage of newborns, with a resultant left to right shunt. This murmur is best heard over the upper left sternal edge, associated with a thrill, and is characteristically continuous and machinery-like. If untreated, the high flow through the pulmonary artery will eventually lead to irreversible pulmonary hypertension with reversal of the shunt flow to right to left (Eisenmenger syndrome). It should be differentiated from a venous hum, a common innocent murmur often heard in children.

Venous Hum http://www.wilkes.med.ucla.edu/Venoushum.htm This is the sound of venous hum, a murmur heard not uncommonly in children. It is usually best heard just above the right clavicle, and radiates into the neck. You will notice that it is a continuous murmur which does not change from systole to diastole, a slight hum in this example which sounds almost like background noise. The intensity of venous hum can be much greater than you hear now, and may be louder in diastole than in systole.

Pulse Palpation 0/4 absence of pulses 1/4 weak; (may suggest impairment) 2/4 normal 3/4 full 4/4 bounding; (may suggest aneurysm, calcification)

Radial Artery Pulse

Popliteal Artery

Femoral Artery

Posterior Tibial Artery Pulse

Dorsalis Pedis Artery Pulse