Download 4c Cardio Exam

History and Physical Examination
You really only need to print the slides
with the stars on them, to remind you
how to perform each part of the
examination.
Sphygmomanometer (BP cuff) $9
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Dual (Double) Head STETHOSCOPE
(BLACK) - LATEX FREE $3.50
•
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Sprague Rappaport Stethoscope $7.50
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History and Physical
• Have the patient fill out a form that asks about
their complete medical history.
• Take their vital signs
• Do a physical exam
Vital Signs
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•
•
•
•
Blood Pressure
Heart Rate
Respirations
Temperature
Height, Weight
• How to measure blood pressure (video)
Blood Pressure
• Use the right size cuff. Pediatric cuffs are available. So are extra large cuffs
and extension wraps for larger patients.
• The patient should not smoke within 30 minutes of blood pressure reading
• The cuff should not be over clothing. It should touch the skin
• The patient’s arm should be supported at a 90 degree angle to the heart.
• The patient’s back should be supported against the back of their chair.
• The patient’s legs should not be crossed
• Wrap the cuff around the arm with the hoses ending at the inner surface
of the decubital fossa (where blood is drawn). Place the diaphragm of the
stethoscope on the decubital fossa, partly under the cuff edge.
• The cuff should not be over the elbow. It should be about 2cm above the
elbow
• The patient should not be talking or engaged in active listening
• For wall-mounted gauges, observer should be at eye level with the gauge
Blood Pressure
• The patient’s arm should be straight at the elbow and
held up at a 90 degree angle by the examiner so that
the arm is at chest level. If the arm is too high or low,
the readings are inaccurate!
• Turn the knob on the bulb to seal the air in. Pump until
the gauge is over 200 mm Hg. Slowly turn the knob on
the bulb the other way to release the air in the cuff and
watch the gauge.
• Listen for the first heart sound and note the gauge
reading. Continue listening for the last heart sound as
it is barely audible and note the gauge reading.
• The two sounds are recorded. Normal is 120/80.
Arm should be at chest level
Wrong
Better
Arm should be at chest level
Correct
Correct arm angle, but she
should be sitting
Ten Errors:
1) Patient’s arm is
unsupported;
2) Patient’s back is
unsupported;
3) Patient is talking;
4) Patient is engaged in active
listening;
5) Wrong size cuff in use
6) Blood pressure cuff is
over the elbow;
7) Cuff is over clothing;
8) Observer is not at eye level
with the wall-mounted
gauge…where is the gauge?
9) Patient’s legs are crossed;
10) End of stethoscope is in
clinician’s coat pocket.
Find ten errors in this picture
Pulse
• Using two fingers (never the thumb, or you will be
feeling your own pulse!), feel along the radius bone at
the base of the patient’s thumb.
• Dig down a little on the medial side.
• Then keep your fingers on that part of the skin, but pull
proximally a little. You should feel the pulse.
• Count how many beats there are for 15 seconds.
• Spend the next 15 seconds in this position, but ignore
the pulse and count the number of breaths they take. If
they know you are counting their breaths, they will not
breathe normally.
• Multiply the heart rate (HR) and the respirations by
four to get the number of heart beats per minute and
the number of respirations per minute.
Stethoscope
Cardiac Auscultation
• Pediatric diaphragms and bells are available accessories for
your stethoscope.
• The examination should be conducted in a warm, quiet
room.
• Warm your hands and stethoscope
• Make sure the earpieces of the stethoscope face forward
before putting them in your ears.
• Stand on the patient's right side
• Stethoscope diaphragm is pressed firmly on the chest, at
four locations
• First sound is S1, second sound is S2
• Repeat auscultation of the four sites with the bell placed
lightly on the chest.
Cardiac Auscultation Sites
Abnormal Heart Sounds
• Friction rubs
• Gallops
• Murmurs
• http://www.wilkes.med.ucla.edu/intro.html
Rubs
• http://www.wilkes.med.ucla.edu/Rubintro.htm
• You are now listening to a typical example of a friction rub.
It is caused by the beating of the heart against an inflamed
pericardium or lung pleura, which itself has a wide variety
of etiologies. This sound is usually continuous, and heard
diffusely over the chest. It typically has three components,
one systolic and two diastolic. The systolic occurs with
ventricular contraction, and the diastolic occurs during both
rapid ventricular filling and atrial contraction. It is
accentuated when the patient sits up and leans forward,
and may be accentuated during inspiration. If the rub
completely disappears when the patient holds his breath it
is more likely due to pleural, not pericardial, origin.
Gallops (S3 sounds)
• http://www.wilkes.med.ucla.edu/Rubintro.htm
• You are listening to a typical example of a third heart sound, or S3.
Shortly after S2, the closing of the semilunar valves, the AV valves
open and diastole begins. Diastole is itself further divided into
several stages, the first being that of rapid filling, where 80% of the
blood stored in the atria during systole is transferred to the
ventricles. At the end of this stage, about 140-160 msec after S2, an
S3 may be heard if the volume which has been transferred is
abnormally large, as in mitral regurgitation. It can be thought of as a
sound which is generated when the ventricle is forced to dilate
beyond its normal range because the atrium has overloaded
volume. An S3 is usually heard best with the bell of the stethoscope
placed at the apex while the patient is in the left lateral decubitus
position. The presence of an S3 is usually normal in children and
young adults, but pathologic in those over the age of 40.
Murmurs
• http://www.wilkes.med.ucla.edu/Rubintro.htm
• You are listening to a typical example of a murmur caused
by a patent ductus arteriosis. This vascular channel
between the aorta and pulmonary artery remains open in a
small percentage of newborns, with a resultant left to right
shunt. This murmur is best heard over the upper left sternal
edge, associated with a thrill, and is characteristically
continuous and machinery-like. If untreated, the high flow
through the pulmonary artery will eventually lead to
irreversible pulmonary hypertension with reversal of the
shunt flow to right to left (Eisenmenger syndrome). It
should be differentiated from a venous hum, a common
innocent murmur often heard in children.
Venous Hum
• http://www.wilkes.med.ucla.edu/Venoushum.htm
• This is the sound of venous hum, a murmur heard not
uncommonly in children. It is usually best heard just
above the right clavicle, and radiates into the neck. You
will notice that it is a continuous murmur which does
not change from systole to diastole, a slight hum in this
example which sounds almost like background noise.
The intensity of venous hum can be much greater than
you hear now, and may be louder in diastole than in
systole.
Pulse Palpation
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•
•
•
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0/4 absence of pulses
1/4 weak; (may suggest impairment)
2/4 normal
3/4 full
4/4 bounding; (may suggest aneurysm,
calcification)
Radial Artery Pulse
Popliteal Artery
Femoral Artery
Posterior Tibial Artery Pulse
Dorsalis Pedis Artery Pulse