CV and Respiratory History &Physical Exam Review

1. CV and Respiratory History &Physical ExamReview 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 • MarritalStatus • Occupation

4. Cardiovascular Exam

5. CV Phys 101 • Inferior vena cava • Superior vena cava • Right atrium • Tricuspid valve • Right ventricle • Pulmonic valve • Pulmonic branch • Pulmonary arteries • Pulmonary veins • Left atrium • Mitral valve • Left ventricle • Aortic valve • Aorta • 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 4th or 5thintercostal 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) 0 • 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 0 • 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: http://www.wrongdiagnosis.com/symptoms/rapid_heart_beat/book-causes-5a.htm

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 • Regurgitation • Aortic • Stenosis • 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- http://meded.ucsd.edu/clinicalmed/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 • Dorsalispedis • 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 • Fascialrestriction • Scan • Auscultation: • Carotid • Temporal • Abdominal aorta • Renal • Iliac • Femoral

34. Lung Exam

35. Surface Anatomy

36. Surface Anatomy

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 • Pectusexcavatum • Pectuscarinatum • 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 0 PectusExcavatum PectusCarinatum

41. Barrel Chest

42. Clubbing 0

43. Palpation: 0 • 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 0

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 • Highpitched; 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 • 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