Cardiovascular Examination & Clinical Decision-Making, PDF

The Abnormal Cardiovascular Examination and Clinical Decision Making Patricia Happel, DO, FACOFP Board Certified Family Medicine Physician Diplomate of the American Board of Obesity Medicine Associate Professor, Family Medicine Department...

The Abnormal Cardiovascular Examination and Clinical Decision Making Patricia Happel, DO, FACOFP Board Certified Family Medicine Physician Diplomate of the American Board of Obesity Medicine Associate Professor, Family Medicine Department Director of Interprofessional Education [email protected]  Session Objectives The student will: 1. Differentiate normal vs. abnormal findings of the cardiovascular history and physical examination. 2. Identify and distinguish abnormal examination findings including murmurs, rubs, and gallops. 3. Develop clinical decision-making process by analyzing and incorporating a patient’s history and physical examination findings to formulate a thorough differential diagnosis, assessment, and plan. 4. Utilize appropriate SOAP note documentation methods relevant to the cardiovascular system.  Cardiovascular Examination Vital signs HR, BP, BMI, Waist circumference Neck JVP, Carotid arteries Chest Cardiac Abdomen Abdominal aorta Lower extremities Pulses, edema Special tests  Vital Signs: Heart Rate and Blood Pressure HR: normal = 60-100 – Tachycardia >100 – Bradycardia 3cm (or possibly 4cm) above the sternal angle  elevated – CHF, Pulmonary hypertension, tricuspid stenosis, pericardial compression/tamponade. JVP falls with hypovolemia and/or loss of blood Carotid upstroke may be: – Brisk – normal – Delayed – suggests aortic stenosis – Bounding – suggests aortic insufficiency Auscultate carotid to assess for bruits Bates’ Guide to Physical Examination and History Taking, 13th edition.  The Cardiac Cycle of Systole and Diastole Systole: the ventricles contract – The right ventricle pumps blood into the pulmonary arteries (pulmonic valve is open) – The left ventricle pumps blood into the aorta (aortic valve is open) Diastole: the ventricles relax – Blood flows from the right atrium → right ventricle (tricuspid valve is open) – Blood flows from the left atrium → left ventricle (mitral valve is open) Bates’ Guide to Physical Examination and History Taking, 13th edition.  Physical Exam - Auscultation Aortic Area 2nd ICS, right sternal border Pulmonic Area 2nd ICS, left sternal border Tricuspid Area 3rd/4th ICS, left sternal border Mitral Area 5th ICS, left midclavicular line Bates’ Guide to Physical Examination and History Taking, 13th edition.  Cardiac Auscultation Auscultate in all listening areas for S1 and S2 using the diaphragm of the stethoscope Then auscultate at the apex with the bell The diaphragm and the bell... – The diaphragm is best for detecting high- pitched sounds like S1, S2, and also S4 and most murmurs – The bell is best for detecting low-pitched sounds like S3 and the rumble of mitral stenosis Bates’ Guide to Physical Examination and History Taking, 13th edition.  Know Your Surface Landmarks Count interspaces – Identify your... o Midsternal line o Midclavicular line o Anterior axillary line o Midaxillary line Bates’ Guide to Physical Examination and History Taking, 13th edition.  Describing Heart Murmurs: Timing and Duration Identify and describe any murmurs Timing: are the murmurs systolic or diastolic? – Tip: palpate the carotid upstroke (occurs in systole) as you auscultate – If the murmur coincides with the carotid upstroke, it is systolic Duration: – Early/mid/late systolic (or holosystolic) – Early/mid/or late diastolic Bates’ Guide to Physical Examination and History Taking, 13th edition.  Describing Heart Murmurs: Shape Shape: Crescendo, decrescendo, or both (“diamond-shaped”) Crescendo – Example: crescendo- decrescendo systolic murmur  aortic stenosis Decrescendo – Example: Holosystolic murmur  mitral Both regurgitation Bates’ Guide to Physical Examination and History Taking, 13th edition.  Describing Heart Murmurs: Quality, Pitch, and Location Quality: Harsh, musical, soft, blowing, or rumbling? Pitch: High-, medium-, or low-pitched? Examples: – Harsh 2/6 medium-pitched holosystolic murmur best heard at the apex  mitral regurgitation – Soft, blowing 3/6 decrescendo diastolic murmur best heard at the lower left sternal border  aortic regurgitation Bates’ Guide to Physical Examination and History Taking, 13th edition. Describing Heart Murmurs: Intensity Approach to Diagnosing Heart Murmurs: Timing and Duration  Assessing the Point of Maximal Impulse The PMI may be: – Tapping — normal – Sustained  LVH [hypertension or aortic stenosis] – Diffuse  dilated ventricle [CHF or cardiomyopathy] PMI location, amplitude, duration, and diameter: –