Physical Exam Lecture 1 Flashcards
9 components of the examination, in order
Inspection of the patient Blood pressure determination Assessment of arterial pulse Determination of respiratory rate Assessment of jugular venous pulsation Carotid Pulsation Palpation of heart Auscultation of heart Examination for dependent edema
Patient positioning during physical exam
Supine
Head of bed may be slightly elevated
Physician positioning during physical exam
Right side of bed
3 questions to ask in terms of general appearance inspection
Is the patient in acute distress?
Is the breathing labored?
Are accessory muscles being used?
3 things to look out for when inspecting skin
Cyanosis
Temperature
Xanthomata
3 types of xanthomata
Tendinous
Tuberous
Eruptive
Describe tendinous xanthomata
Stony-hard, slightly yellowish masses in extensor tendons of:
- fingers
- Achilles
- plantar tendons of the soles
Describe tuberous xanthomata
Palms, soles, knees, elbows, hands
Occur in 15% of patients with primary biliary cirrhosis
Describe eruptive xanthomata
Small 1 - 3 mm in diameter, yellowish papules on an erythematous base found on buttocks, abdomen, back, face and arms
What are Osler’s nodes?
Painful lesions in the tufts of fingers and toes
What are Janeway lesions?
Non-painful, small erythematous macular on the palms and soles
What do Osler’s ndoes and Janeway lesions indicate?
Infective endocarditis
Define splinter hemorrhages upon nail inspection
Small, reddish-brown lines in the nail bed
What are splinter hemorrhages a sign of?
Infective endocarditis
What is Lichstein’s sign?
Oblique earlobe creases, often bilateral, seen in patients over 50 years of age with significant coronary diseease
Two manifestations that can be found upon eye inspection
Xanthelasma
Arcus Senilis
Define xanthelasma
Yellowish plaques on the eyelids (less specific for dyslipidemia than the xanthoma)
Define arcus senilis
Silver rim around dark of eye, seen in patients younger than 40 years of age
What to suspect upon finding arcus senilis
Dyslipidemia
Define palatal petechiae
Red dots on palate of mouth
What is palatal petechiae a sign of?
Endocarditis
2 potential findings upon chest configurations inspection
Pectus excavatum (caved in chest) Pectus carinatum (Pigeon breast)
What is pectus excavatum a sign of?
Marfan’s and mitral valve prolapse
What is pectus carinatum a sign of?
Marfan’s syndrome
What is an extra phalanx, finger or toe a sign of?
Atrioseptal defect (ASD)
What are long,slender fingers a sign of?
Marfan’s syndrome
What is short stature, cubitus valgus and medial deviation of the forearm a sign of?
Turner’s syndrome
4 essential ingredients for determining BP
The Patient: Preparation and positioning
The Clinician: Positioning
The Instrument: Accuracy
The Procedure: Skill
4 ways to ensure patient preparation and positioning
Patient avoids smoking or drinking caffeinated beverages
Patient rests for 5 min in a quiet, comfortably warm room
Arm is free of clothing and should be supported at heart level
Palpate brachial artery
Width requirement for a correctly-sized BP cuff
Width of inflatable bladder should be 40% of the upper arm circumference
Length requirement for a correctly-sized BP cuff
Length of the inflatable bladder should be 80% of the upper arm circumference
Problem with have a cuff that is too small. Too big?
Small = May overestimate the BP Big = may underestimate BP
Problem with putting on the BP cuff too loosely
May overestimate BP
How should the cuff be positioned on the patient’s arm?
The lower border of the cuff should be 2.5 cm above the antecubital crease
How to avoid error by the auscultatory gap
As you feel the radial artery with the finger of one hand, inflate the cuff until the radial pulse disappears. Add 30 mm Hg
As you deflate the cuff, the pressure on the manometer at which the radial pulse re-appears = systolic BP by palpation
Deflate the cuff promptly and completely –> wait 15 - 30 sec
How to determine the BP after complete preparation
Use bell of stethoscope
Deflate cuff at 2 - 3 mm Hg per second
Systolic BP = first sound of at least 2 consecutive heartbeats
Diastolic BP = muffling and disappearance of the heartbeats (only a few mm apart)
Read these 2 values to the nearest 2 mm Hg
Wait 2 or more min and repeat (in both arms)
Method for assessing heart rate
Use radial pulse with the pads of your index and middle fingers
Gradually compress the radial artery until the maximal pulsation is detected
Normal or regular = measure over 30 sec
Fast or slow = measure over 60 sec
If the rhythm is irregular, how do you measure rhythm?
Use stethoscope at the cardiac apex
Most common cause of irregular rhythm
Premature beat
5 things to assess for the respiratory rate
Observe the: rate, rhythm, depth and effort of breathing
Count the number of respirations by visual inspection
Normal respiratory rate
20 breaths/min
2 reasons why the assessment of jugular venous pressure is important
Provides the astute clinician with an index of RH P and cardiac function
Clinician’s window to the assessment of intra-vascular space and/or intra-cardiac P –> provide invaluable info on the presence or absence of heart disease
What doe JVP reflect?
Right atrial P = CVP = RV EDP
Where is the jugular venous pulsation found?
Deep to the sternomastoid muscle
Not directly visible
4 steps to JVP technique
1 - position patient
2 - distinguish internal jugular with carotid pulsations
3 - estimation of the height of the JVP
4 - evaluation of the various waveforms
What does inclination change in determining JVP?
Ability to measure the height of the column of the venous blood
What do you consider when inclining the patient for JVP?
Consider/anticipate the patient’s volume status
Usually start at 30 degrees (head elevation)
If hypovolemic, how to incline patient for JVP
Lower head of the bed to 0 degrees
If hypervolemic, how to incline patient for JVP
Elevate bed to 60 - 90 degrees
3 considerations for positioning after successfully inclining the patient for JVP
Tilt patient’s head away from the side you are inspecting
Tangential lighting
Tangential inspection (i.e. lean towards bed’s midline for examination)
What 2 factors make the assessment of the JVP not possible?
A large neck
Excessive use of accessory muscles (particularly of the sternomastoid)
Difference between carotid pulsation vs. JVP palpability
Carotid = palpable JVP = rarely palpable
Difference between pulsation quality of carotid vs. JVP
Carotid = More vigorous thrust with a single outward component JVP = Soft, biphasic, undulating quality, usually with two elevations and two troughs per heart beat (a and v waves of AP graph)
DIfference in pulsation elimination between carotid vs. JVP
JVP = pulsations eliminated by light P on the vein(s) jsut above the sternal end of the clavicle
Carotid = pulsations not eliminated by this P
Difference in pulsation height due to position between carotid and JVP
JVP = height changes with position, dropping as the patient becomes more upright
Carotid = Height unchanged by position
Difference in pulsation height due to inspiration
JVP = usually falls with inspiration
Carotid = usually not affected by inspiration
What is an elevated JVP?
> 3 - 4 cm above sternal angle, or by adding a distance of 5 cm, > 8 - 9 cm above the RA
Timing of a wave
Precedes the S1/carotid pulse
Timing of x descent
Coincides with systole
Timing of v wave
Almost coincides with S2
Timing of y descent
Almost follows early diastole
Why is assessing carotid pulse important?
Provides valuable information on:
- Cardiac function
- Stenosis or regurgitation of the aortic valve
Defining characteristics to assess quality of the carotid pulse
Amplitude and contour
Bruits and thrills
Patient positioning for carotid pulsation
Head of bed elevated to 30 degrees
Clinician position for carotid pulsation
Stand slightly behind of the patient on right side
Location of carotid pulse
Medial to a well-relaxed sternomastoid muscle at the level of the cricoid cartilage
Method to take the carotid pulse
Use index and middle finger (or thumb) in the lower third of neck
Slowly increase P until you feel max pulsation
Slowly decrease P until you sense arterial P and contour
Define amplitude of carotid pulsation
Pulse pressure
Define contour of carotid pulsation
Speed of the upstroke, duration, speed of downstroke
Define thrills
Humming vibrations (i.e. like throat of purring cat)
4 positions for cardiac examination, in order of sequence
Supine, with head elevated 30 degrees
Left lateral decubitus
Supine, with head elevated 30 degrees
Sitting, leaning forward, after full exhalation
Cardiac Examination: how to examine a patient in the first supine position with head elevated 30 degrees
Inspect and palpate the precordium: the 2nd right and left interspaces; the right ventricle; the left ventricle, including apical impulse (diameter, location, amplitude, duration)
Cardiac Examination: how to examine patient in left lateral decubitus position
Palpate the apical impulse if not previously detected
Listen at apex with the bell of the stethoscope
Cardiac Examination: how to examine a patient in the second supine position with head elevated 30 degrees
Listen at the 2nd right and left interspaces, along left sternal border, across to apex with diaphragm
Listen at right sternal border for tricuspid murmurs and sounds with the bell
Cardiac Examination: how to examine a patient sitting, leadning forward, after full exhalation
Listen along the left sternal border and at the apex with the diaphragm
Accentuated findings in the left alteral decubitus position during cardiac examination
Low-pitched extra sounds such as an S3, opening snap, diastolic rumble of mitral stenosis
Accentuated findings in sitting position furing cardiac examination
Soft decrescendo diastolic murmur of aortic insufficiency
What is the apical impulse?
The breif early pulsation of the LV as it moves anteriorly during contraction and touches the chest wall. PMI (point of maximal impulse) in most cases.
What to assess when palpating for the apical impulse
Location (vertical and horizontal)
Diameter
Amplitude
Duration
Usual location of apical impulse
Vertical location is usually the 5th or even 4th interspace
Normal apical impulse diameter
Supine = 2.5 cm or only 1 interspace
What is the significance of a larger diameter of apical impulse?
Enlarged left ventricle
Usual apical impulse amplitude
Brisk and tapping
Normal duration of apical impulse
Proportion of systole occupied by the apical impulse (usually does not continue to S2)
Where to position fingers when palpating the right ventricular area
Place tips of fingers in the left 3rd, 4th and 5th interspaces. Palpate at end-expiration
What to assess when palpating right ventricular area
Location, amplitude, duration
Significance of high amplitude but not duration in right ventricular area palpation
Chronic RV volume overload
Significance of high amplitude and duration in right ventricular area palpation
Chronic RV pressure overload
How to “inch your stethoscope” during auscultation
Start at apex, inch toward LLSB, 2nd L. interspace and 2nd R. interspace
How to use carotid pulse concurrently with auscultation to accurately identify S1 and S2
S1 occurs prior to the upstroke
S2 follows the carotid upstroke
What kinds of sounds can the diaphragm of the stethoscope hear best?
High pitched sounds (S1, S2, murmurs of AR/MR, mid-systolic clicks, ejection sound, opening snap, pericardial friction rubs)
What kind of sounds can the bell of the stethoscope hear best?
Low-pitched sounds (S3, S4, mitral stenosis)
2 maneuvers that increase preload
Squatting position
Release of the Valsalva maneuver (phase 4)
2 maneuvers that decrease preload
Standing for the squatting position
During the strain of the Valsalva maneuver (phase 2)
1 maneuver that increases afterload
Handgrip
8 categories of information to obtain when assessing murmurs
1) In systole or diastole?
2) Location
3) Radiation
4) Timing
5) Shape
6) Intensity
7) Pitch
8) Alleviating and aggravating factors
