Lab- Cardiac, Rib HVLA, and Counterstrain Flashcards
First thing to do in Physical Exam for Cardiac complaint?
Inspection - general appearance (cyanosis, posture, resp distress, etc) Chest shape (barrel chest, pectus carinatum, pectus escavatum)
Landmarks of Cardiac physical exam?
- Sternal notch
- Sternal angle
- Xiphoid process
- Costochondral joints & Intercostal muscles
TART screen of cardiac physical exam?
- Is the pain reproducible? If yes, MSK is most likely (Only 3% of cardiac pain is reproducible)
- Pain from rib dysfunction is often experienced at the anterior intercostal spaces with associated intercostal spasm
Chapman’s Points of cardiac complaint?
Autonomic Associations of cardiac complaint
- Sympathetic
- Heart: T1-6
- Upper GI: T5-10
- Adrenals: T5-10 (T10)
- Parasympathetic
- Vagus = Suboccipital
Point of Maximal Impulse (PMI)
- Estimates the size of the heart and location of the apex of the heart
- Assessment:
- Supine or Lateral Recumbent
- 5th Intercostal space in the mid-clavicular line
- Normally <2.5cm (quarter size)
- >2.5 indicative of LVH or dilated cardiomyopathy
- Palpation may be easier leaning forward or left lateral recumbent
Auscultation of Cardiac physical exam - Listening posts
- Aortic valve: right 2nd ICS at sternal border
- Pulmonic valve: left 2nd ICS at sternal border
- Tricuspid valve: left 4th ICS at sternal border
Mitral valve: left 5th ICS at mid-clavicular line
Auscultation of cardiac sounds - what is the process and what is important to note?
- ALWAYS LISTEN ON BARE SKIN!
- Listen to all 4 posts with diaphragm AND bell
- S1, S2, AR, MR: Better heard with diaphragm
- S3, S4, MS: Better heard with bell
- Listen for S1 and S2 (Lub Dub)
- Get in touch with the pattern/rhythm (a-fib, early beat, pause)
- Then listen in between the beats for extra sounds: murmurs, clicks
- After LubDub = diastolic, S3 or S4
- In between = systolic
Systolic Murmurs, when are they heard? - cardiac physical
- Systolic = Between S1 and S2
- AS, PS, MR, TR
Diastolic Murmurs, when are they heard?
- Diastolic = Between S2 and S1
- AR, PR, MS, TS
How do we grade heart sound murmurs?
- Grade 1: Very faint
- Grade 2: Quiet, but heard easily with stethoscope
- Grade 3: Loud, NO thrill
- Grade 4: Loud WITH a thrill
- Grade 5: Very loud with a thrill
- Grade 6: Heard with stethoscope off chest
How do we grade pulses?
- 0 = Absent, Not palpable
- 1+ = Diminished
- 2+ = Normal
- 3+ = Bounding, Increased
- Always assess bilaterally!
How to assess Carotid pulse during cardiac physical exam
- Medial to the SCM
- DO NOT ASSESS SIMULTANEOUSLY!
- Pressure on the carotid baroreceptors may cause a hypotensive reflex and possible syncope
- Carotid Bruits
- Use the bell of the stethoscope
- Have patient hold breath, and listen to the artery
Importance of capillary refill in cardiac physical exam? How to do it?
- Tests digital perfusion
- Apply pressure to fingernail/toenail until blanching
- Remove pressure
- Note the time it takes for color to return
- Normal = <3 seconds
Vascular testing in cardiac physical exam, what do we check?
Pulses, carotid pulse, capillary refill, peripheral edema
Peripheral edema - how to do it, what is grading scale?
- Press over bone firmly for five seconds, then release
- Most commonly on anterior tibia
- Grading
- 0 = Absent
- 1+ = 2mm indentation, disappears rapidly
- 2+ = 4mm indention, disappears 10-15 sec
- 3+ = 6mm indentation, disappears >1 min
- 4+ = 8mm indentation, disappears 2-5 min
Cardiac physcial exam special tests - what are they?
Jugular Venous Pressure (JVP)
Allen Test
What is Jugular Venous Pressure test?
- Measures jugular venous distention (JVD)
- Best estimated over right internal jugular vein
- Behind SCM
- Raise head of bed to 30⁰, turn patient’s head slightly left
- Identify the most superior point of pulsation and distention
- JVP = vertical distance from sternal angle to highest point of pulsation + 5cm
- Hepatojugular reflux (HJR) = jugular distention with liver pressure demonstrates abdominal and liver edema
what is the allen special test?
- Evaluates the presence and function of radial and ulnar arteries
- Occlude both arteries, have patient open and close fist until palm blanches
- Release pressure of ulnar artery and observe color return
- Repeat with radial artery
- Normal = 5-10 seconds
- >10 seconds is delayed
- Clinical use: Demonstrates absence of either artery and is therefore a contraindication for radial catheterization
Rib Somatic Dysfunction- BITE mneumonic
Bottom Inhalation Top Exhalation
-
_B_ottom _I_nhalation
- If a group of ribs is found to have inhalation SD, the bottom of the group is the key rib
- Inhalation dysfunction = treat inferior rib
-
_T_op _E_xhalation
- If a group of ribs is found to have exhalation SD, the top rib of the group is the key rib
- Exhalation dysfunction = treat superior rib
- Key rib = the rib that maintains a group in dysfunctional motion
- Treat this rib FIRST
Rib Counterstrain - anterior rib tender points
Rib Counterstrain anterior rib 1 & 2
FSRT
- Patient supine or seated
- Lift head and neck ~40 degrees
-
Sidebend & Rotate Toward the side of the dysfunction
- Expect about 45 degrees of each
Pro-tip: ribs 1&2 are often elevated because of the scalenes. This position also places them at ease.
Rib Counterstrain: Anterior rib 3-10
f-FRST
- Pt. seated
- Place pt’s arm on side opposite dysfunction on your knee
- Slightly Sidebend & Rotate trunk Toward dysfunction
- Add flexion
Rib Counterstrain - posterior rib tenderpoints
Rib Counterstrain: Posterior rib 1
MAVERICK - eSaRt-T
- Pt seated or supine or other creative position as needed
- Add slight Extension
- Slightly Sidebend Away
- Moderately Rotate Toward
- Balance tissues at the level of the dysfunction
Rib Couterstrain: Posterior rib 2
fSARA
- Pt seated or supine or other creative position as needed
- Flex head
- Sidebend & Rotate the trunk/neck Away
- Balance tissues at the level of the dysfunction
Rib Counterstrain: Posterior ribs 3-10
FSARA
- Pt seated
- Support arm of side of dysfunction on top of your knee
- Grasp shoulder or brace head
- Sidebend & rotate superior portion (head or torso) away
- Balance at level of the dysfunction
Pro-tip: elevates the affected inhaled rib
