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Continuing Medical Education Programs
Dr. Anika Niambi Al-Shura, Lecturer
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Integrative Examination in
Cardiovascular Disease
Copyright 2014 Niambi Wellness. All rights reserved
This course is approved by the
following agencies:
National Certification Commission for Acupuncture and
Oriental Medicine (NCCAOM) for 9 PDA points and
Florida State Board of Acupuncture for 12 CEUs.
The companion textbook:
Physical Examination in
Cardiovascular Chinese Medicine
must be ordered at www.elsevier.com
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Course Description
This course focuses on the basic cardiac patient
examination routine using protocols of both
western medicine and TCM.
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Course Objectives
• Understand the basics of how to take a cardiac
patient history and triage vitals.
• Understand blending of basic western and TCM
methods for examining cardiovascular patients
in the clinic.
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Copyright 2014 Niambi Wellness. All rights reserved
Course Modules
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Module 1:
Hypertension and Arrhythmia Questionnaire
Module 2:
The Triage
Module 3:
Exam Room I
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Module 3
Exam Room I
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Contents
Chapter 5:
Physical Exam Basics
Chapter 6:
Tongue and Pulse Diagnosis
Chapter 7:
Putting it all together
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Copyright 2014 Niambi Wellness. All rights reserved
Chapter 5: Physical Exam Basics
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Contents
Part 1:
Preparation
Part 2:
Cardiac Palpation
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Contents
Part 3:
Respiratory Palpation
Part 4:
Cardiac and Pulmonary Auscultation
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Part 1: Preparation
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Draping and Positioning
Physical examination of a heart patient should
include observation, palpation and auscultation.
Percussion is used some times to inspect the
abdomen, but not used in the cardiac exam.
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Help the patient upon the exam table into a
common position done during the cardiovascular
exam.
These include: dorsal recumbent, Fowler’s, supine
or Trendelenburg’s
For pulses, the Fowlers position (face up) is best.
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The patient position on the table should be
supine with the upper body elevated 30 to 45
degrees.
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The patient should be completely naked under a
robe or gown, which is open in the front. Female
patients should remove the bra.
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The patient draping is important because it
provides modesty. All areas should be covered
except for the area to be examined.
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The room should be quiet with plenty of light for
listening and observing.
Always explain what you are doing in the exam.
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Enlist a female
patient's assistance
by asking her to lift
their own breast
during the precordial
palpation, and at
auscultation.
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Part 2: Cardiac Palpation
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Carotid Artery Palpation
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Carotid Artery Palpation
This exam detects
atherosclerosis,
severe impairment of
the ventricles and
aortic stenosis.
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To locate the carotid
artery, gently slide
your fingers along the
side of the trachea at
the level of the thyroid
cartilage.
Palpate one side at a
time.
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Jugular Venous Pressure
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Jugular Vein
When assessing the right jugular venous
pressure (JVP), you view the internal jugular
vein by asking the patient to turn the head
slightly.
You should you notice the pulsation of the vein
beneath the belly of the sternocleido mastoid
muscle.
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If gentle pressure on the right costal area of the
abdomen produces a JVP elevation of more
than 5 seconds the patient may have
hypertension, right ventricular failure, valvular
stenosis or regurgitation
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If you cannot see the vein you must do the
hepato- jugular reflex maneuver.
To do this, slightly push the side of the head
as the patient resists.
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A raised vein may be a sign of right heart failure.
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Precordial Examinan
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Precordial Examination
This exam detects
palpable cardiac
problems.
Cover the chest area
of the heart with the
palm of your hand.
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Have the patient turn
to their side in the left
lateral decubitus
position.
This brings the heart
closer to the chest
wall and makes the
PMI more obvious.
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You should feel the
point of maximum
impulse (PMI), which
is located at the point
of the mid-clavicular
line at the 5th
intercostal space.
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Sensations include:
• pulse transmission
• thrills
.
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Pulse transmission is
a vigorous sensation
which is associated
with mitral
regurgitation and
ventricular
hypertrophy.
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A thrill is a vibration
due to the turbulent
flow through a valve,
suggesting a valve
abnormality.
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Bruits
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Bruits
Listening for this can be done at any artery to
detect the presence of thrombosis, occlusion or
inflammation.
Bruits may be associated with the presence or
recovery from atherosclerosis.
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The sound of bruits is the turbulent flow through
the artery which is at least 50% occluded.
As the artery become more narrow the sound
increases until the narrowing becomes more
serious. Then the sound begins to reduce.
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Carotid Bruit
After chest
auscultation, return to
the carotid artery to
listen for bruit.
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To listen for bruit,
have the patient
briefly hold their
breath, then place the
diaphragm gently
over each carotid
area. A bruit gives a
“woosh” sound.
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Valsalva Maneuver
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Valsalva Maneuver
This helps detect heart abnormalities, treat
abnormal heart rhythms or relieve chest pain.
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The seated patient squeezes the nose and
mouth shut, while blowing out and bearing down
as if having a bowel movement.
This raises the heart rate and blood pressure.
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Auscultation or echocardiography during the
Valsalva maneuver, can detect any changes in
rate, sound and pressure which brings out any
latent heart diseases.
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The Valsalva maneuver also corrects atrial
tachycardia, forcing the heart to beat more
slowly, or diminish chest pain in mild coronary
artery disease.
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Part 3:Respiratory Palpation
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Physical examination of the lungs should include
observation, palpation and auscultation.
Percussion is used in the respiratory exam.
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Observation
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Observation
The respiratory exam
should be performed
while the patient is
seated on the table.
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First, help the patient
sit up and swing both
legs to position them
hanging off the side of
the table.
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A lot of information about a patient can be
gained from watching a patient breathe face to
face.
Notice if the breathing seems shallow, deep,
regular or irregular.
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Notice if the breathing appears to be distressed
or labored. The use of the accessory muscles is
a sign of respiratory difficulty.
Notice the color of the lips and nail beds for pale
or blue color, which is a sign of cyanosis. This
means insufficient amount of oxygen.
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Notice if the patient breathes through pursed
lips, whispers, speaks softly or with a rasp.
Notice if there is any wheezing, gurgling,
fremitus or crackles in the breathing. These are
heard in pleural effusions and consolidation.
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Next, stand behind the patient, partially to the
side.
Then move the draping away to expose the
back.
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Palpation
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Palpation
Touching the back is
good for identifying
areas of pain, skin
temperature changes.
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Notice if the spine is curved with kyphosis along
with a concave chest.
These are characteristic in emphysema and
COPD.
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Percussion
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Percussion
This method detects
whether the lungs are
clear, filled with air or
fluid.
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Place last 2
phalanges of your left
middle finger on the
patient’s back.
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Tap the joint twice
with the middle and
index fingers of the
right hand to produce
sound.
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Slide around to repeat
this method in other
areas of the lung field,
to notice changes in
tone quality.
Avoid the scapula and
spine.
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Notice sound tones
similar to thumping a
melon, drum or solid.
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Tone Qualities
Normal lungs produce a tone like thumping a
melon.
Lungs with chronic or acute diseases that trap
air produce tympany, a tone like a drum.
Lungs filled with fluid, pleural effusion and
pneumonia produce a tone like tapping a solid
surface.
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Part 4:Cardiac and
Pulmonary Auscultation
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Normal Sounds
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Normal Sounds
1. Aortic
2. Pulmonic
3. Tricuspid
4. Erb’s point
5. Mitral
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S2 is Loudest
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S2 is loudest
6. Aortic valve
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7. Pulmonic valve
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Spitting S2 is Loudest
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Splitting S2 is loudest
8. Each intercostal
space to
9. Apex
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S1 is Loudest
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S1 is loudest
10. Tricuspid valve
11. Mitral valve
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Using the bell picks
up low pitched
sounds.
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Summation Gallops
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S3 is loudest
12. Mitral
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Regurgitation
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13. Mitral
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Part 4:Cardiac and
Pulmonary Auscultation
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Using the diaphragm
picks up high pitched
sounds.
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Wheezing
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1. trachea
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Stridor
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2. trachea
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Crackles
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3. lobes and alveoli
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Chapter 6: Case Studies I
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Contents
Part 1:
4 cases
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Case #1
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Case #1
1.
2.
3.
4.
Thick or thin size
Pale
White coating
Greasy coating
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Case #2
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Case #2
1.
2.
3.
4.
Pale
Purple
Scanty fur
Ecchymosis
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Case #3
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Case #3
1.
2.
3.
4.
Red
Tooth marks
Scanty yellow coat
Ecchymosis
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Case #4
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Case #4
1.
2.
3.
4.
Pale
Swollen
Tooth marks
Thin coat
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Chapter 7: Case Studies II
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Case #1
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Case #1
Western diagnosis:
Hypertension
TCM treatment
principle:
Remove stasis
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Case #2
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Case #2
Western diagnosis:
Peri-menopausal
TCM treatment
principle:
Warm and invigorate
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Case #3
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Case #3
Western diagnosis:
Prostate inflammation
TCM treatment
principle:
Nourish and tonify
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Case #4
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Case #4
Western diagnosis:
Pre-hypertension
TCM treatment
principle:
Regulate chong and ren
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Case #5
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Case #5
Western diagnosis:
High LDL levels
TCM treatment
principle:
Transform phlegm
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Case #6
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Case #6
Western diagnosis:
Hypertension
TCM treatment
principle:
Transform phlegm
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Module 1 Review
Questions
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According to the textbook
.
Review the Module review questions.
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According to the course
1. List important areas in cardiac auscultation.
2. List the important sounds heard in those
important areas.
3. Which pitches are heard at the bell and
diaphragm?
4. What common heart condition are the tongue
qualities associated with?
5. List the Western medicine diagnoses and
treatment principles associated with each case.
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Complete the Module 3
review interactive practice quiz.
Listen to the cardiac and respiratory
auscultation media library.
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Course Conclusion
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