CV and Respiratory History &Physical Exam Review Family Medicine Fellows

Overview CV Exam Lung Exam History Inspection Palpation Auscultation Percussion Auscultation

Subjective-Review Family history Social history 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 Inferior vena cava Pulmonary veins 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

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

Inspection Look for Where could there be pulsations? What is normal? 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 Palpate: Thrills 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) NORMALLY: none found Precordium: The area on the anterior surface of the body overlying the heart and lower part of the thorax

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 How do we describe rhythm? Regular Irregular Regularly irregular Irregularly irregular

Heart Sounds (Normal) What are normal sounds? What is S1? What is S2? 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) S1-lub S2-dub We can tell the difference by feeling pulse for S1: should happen at the same time Systole between S1 and S2 shorter time than diastole between S2 and S1

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 Yes sometimes an split S1 is pathologic (not normal physiology).

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: Diastolic: 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.” This particular description is characteristic of a mitral regurgitation.

Examples of Murmurs Mitral Stenosis Regurgitation Aortic

Other Sounds Click Snap Rub Abrupt and brief Sharp cracking sound; classic description of S1 in mitral stenosis Rub Friction of one surface moving over another

Further characterizing Sounds Different maneuvers can increase or decrease the sound of different murmurs or other sounds. Standing is the same as straining on valsalva: it decreases venous return Squatting same as releasing a valsalva: increased venous return

Practice Inspect Auscultate Palpate Osteopathic 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 1. Superior vena cava, 2. left innominate vein (common jugular), 3 right innominate vein 4.subclavian vein 5. internal jugular vein…8 common carotid, 9 subclavia Demonstration- http://meded.ucsd.edu/clinicalmed/cvp_movie.htm

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

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 Objective is going to be restriction of the fascia in area x. and SD of whatever region

Palpation of PV system Capillary Refill Grading of Pulses Pulses ≤ 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 Auscultation: 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 Percussion Ausculate Palpate 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 Breathing Issues Cyanosis Clubbing 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 Inspect inspiration expiration Hyper if there is associated with dysfunction

Chest Deformities Pectus Excavatum Pectus Carinatum

Barrel Chest

Clubbing

Palpation: Trachea Tactile fremitus 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 practice

Auscultation Normal sounds: loudness Vesicular- I > E Bronchovesicular- I = E Bronchial- E > I Tracheal- I = E Only normal if heard in the right place! Vesicular: Periphery Bronchovesicular-anteriorly 1st&2nd ICS; bet. Scapulae Bronchial-manubrium Tracheal-neck over trachea

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 From ucsd site in resources: Wheezing heard only on inspiration is referred to as stridor Rhonchi: gurgling-type noise, similar to the sound produced when you suck the last bits of a milk shake through a straw. Rales (a.k.a. crackles) are scratchy sounds that occur in association with processes that cause fluid to accumulate within the alveolar and interstitial spaces. The sound is similar to that produced by rubbing strands of hair together close to your ear. Dry crackles sound like velcro

Practice! Inspection of chest Percussion Ausculate Palpate Osteopathic 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 Lung exam All Inspect 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