Bates Guide To Physical Examination And History Taking

This article begins with a brief overview of health history taking followed by the anatomy of the vascular structures of the neck examination of jugular venous pressure and the carotid pulse anatomy of the heart inspection palpation and all skhul tation of the heart a description of heart sounds and attributes and grading of murmurs. 

Bates Guide To Physical Examination And History TakingAdd caption

Bates Guide To Physical Examination And History Taking

We conclude the video with hips on describing your findings you will see the examiner assess a healthy patient and clinical practice you may detect the same normal findings or you may discover normal variations or abnormal findings the health history interview is a conversation with a three-fold purpose to establish a trusting and support a relationship to gather information and to offer information in the case of new patients.

you will gather information that will form the basis for a comprehensive written health history for patients seeking care for a specific complaint you may prepare a more focused problem-oriented history in either case you will record the patient's chief complaint along with common or concerning symptoms common or concerning symptoms relating to neck vessels and the heart include chest pain palpitations and shortness of breath orthopnea or paroxysmal nocturnal dyspnea by eliciting the patient's concerns before the examination you prepare for an examination that is efficient and productive a productive cardiovascular examination also requires. 

Physical Examination And History Taking

That you think about the possible meanings of your individual observations fit them together in a logical pattern and correlate your cardiac findings with the patient's blood pressure arterial pulses venous pulsations jugular venous pressure the remainder of your physical examination and the patient's history with the patient's health history in mind you are now ready for the examination before beginning let's review the three key cardiovascular structures in the neck the carotid artery the internal jugular vein and the external jugular vein the carotid. 

Artery is deep to the sternum mastoid muscle the internal jugular vein lies beneath of the sternal mastoid muscle adjacent to the carotid artery the internal jugular vein is not normally visible the external jugular vein runs at an angle along the sternal mastoid muscle toward the clavicle the external jugular can be observed fairly easily jugular venous pressure or jvp is a measurement of the elevation at which the highest oscillation point or meniscus of the jugular venous pulsations is usually evident the measurement reflects pressure in the right atrium. 

That is central venous pressure estimating the patient's jvp is one of the most important and frequently used skills of physical examination and often the first step in your cardiovascular assessment in the beginning estimating the jvp will seem difficult but with time you will find that the jvp provides a valuable information about the patient's of Varnum status and cardiac function the jvp is best assessed from pulsations in the right internal jugular vein raise the head of the examining table to 30 degrees and with the patient supine place the patient's head on a pillow to relax the sternal mastoid muscles then adjust the patient's count and rate using tangential lighting. 

Physical Examination Format PDF

If necessary examine both sides of the neck then turn the patient's head slightly to the left since the physical examination is conducted from the patient's right side focusing on the right side identify the external jugular vein then find the internal jugular venous pulsations if necessary raise or lower the head of the bed until you can see the oscillation point of the internal jugular venous pulsations in the lower half of the neck look for the oscillation point along the sternal mastoid muscle between the clavicle and the angle of the jaw or just posterior to the sternomastoid internal jugular pulsations have a soft rapid undulating quality usually with three elevations per heartbeat. 

Two of which are visible and two troughs whereas the carotid pulse provides a more vigorous thrust with a single outward component internal jugular pulsations are rarely palpable whereas the carotid pulse is almost always palpable internal jugular pulsations are eliminated by light pressure on the vein just above the sternal end of the clavicle the carotid pulse is not eliminated by the pressure the level of internal jugular pulsations changes with position in a euvolemic patient the level in the neck drops as the patient becomes more upright whereas the carotid pulse is unchanged by position finally the level of internal jugular pulsations usually descends with inspiration whereas the carotid pulse is not affected by inspiration measure. 

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The oscillation point of pulsation in the right internal jugular vein using the following technique extend an elongated rectangular object such as a 3x5 card from the meniscus point of pulsation while extending a centimeter ruler vertically from the sternal angle making a right angle establishing the true vertical and horizontal lines to measure the jvp may be difficult as you place your ruler on the sternal angle line it up with something in the room that you know to be vertical then place your card or other rectangular object at an exact right angle to the ruler this constitutes your horizontal line now place the card at the point of oscillation of the jugular venous pulsations making sure to keep the card horizontal

 then read the vertical distance.

Annual physical exam checklist

Where the card crosses the ruler this measurement identifies the jugular venous pressure or JDP the vertical distance in centimeters above the sternal angle where your card crosses the ruler round your measurement off to the nearest centimeter in this patient the jvp is about one centimeter above the sternal angle with the head of the bed elevated 30 degrees the venous pressure is elevated above normal when it measures at greater than three to four centimeters above the sternal angle or more than seven to eight centimeters in total distance above the right atrium with the bed elevated to 30 degrees the steps for measuring the jvp when funneled carefully result in a measurement. 

Bates Guide To Physical Examination And History TakingAdd caption

That is important for assessing the intravascular volume status and euvolemic hypervolemic or hypovolemic patients Nach assess the carotid pulse the carotid pulse provides valuable information about cardiac function and is especially useful for detecting aortic valve stenosis or aortic insufficiency your assessment will include both palpation to assess the amplitude and contour of the carotid of stroke and auscultation for the presence or absence of overlying brewery's you should assess both the right and left carotid arteries then compare however do not press on both carotid arteries at once assessment of a right. 

Carotid artery is demonstrated here with the patient still lying supine and with a head of the bed or examining table still elevated to above 30 degrees inspect the neck for carotid pulse ations place your index and middle fingers or your thumb on the right carotid artery in the lower third of the neck you should press just inside the medial border of a well relaxed sterno mastoid muscle roughly at the level of the cricoid cartilage slowly increase pressure until you feel a maximal pulsation then slowly decrease pressure until you best sense their arterial pressure wave and contour try to assess the amplitude of the pulse this correlates reasonably well with the pulse pressure. 

The contour of the pulse wave that is the speed of the upstroke the duration of its summit and the speed of the down stroke the normal upstroke is brisk smooth and rapid and follows s1 almost immediately the summit is smooth rounded and roughly mid-systolic the down stroke is less abrupt than the up stroke during palpation of the carotid artery you may detect humming vibrations or thrills that feel like the throat of a purring can't routinely but especially in the presence of a thrill you should listen over both carotid arteries with a diaphragm of your stethoscope ask the patient to hold breathing for a moment.

 

Physical Examination Steps

So that breath sounds do not obscure the vascular sound listen for a bruit which is a whooshing murmur like sound of vascular rather than cardiac origin a bruit suggests arterial narrowing if present a bruit would sound like this you should also assume for breweries over the carotid arteries if the patient is middle-aged or elderly or if you suspect cerebrovascular disease note that heart sounds alone do not constitute a bruit most of the anterior surface of the heart is made up of the right ventricle the left ventricle lies to the left of and behind the right ventricle it forms the left border of the heart and produces the apical impulse. 

The apical impulse is a brief systolic beat usually found in the left fifth interspace about seven to nine centimeters from the mid sternal line the impulse measures about the size of a quarter roughly one to 2.5 centimeters in diameter the right atrium forms the right border of the heart the left atrium is mostly posterior neither the right or the left atrium can be examined directly above the heart lie the great vessels the pulmonary artery arises from the right ventricle and quickly bifurcates into its left and right branches the aorta arises from the left ventricle your examination of the heart will consist of inspection palpation and auscultation. 

Let's begin with inspection and palpation to examine the heart stand at the patient's right side have the patient remain supine with the upper body raised to above 30 degrees first inspect the anterior chest noting any heaves or lifts none are observed here careful inspection may also reveal the location of the applica impulse when visible the apical impulse is normally seen in the left fifth interspace at or medial to the midclavicular line later in the examination you will palpate to more clearly identified the apical impulse following inspection proceed with general palpation of the chest wall first palpate for impulses using your finger pads hold and slant or oblique ly on the body surface as you palpate at the right and left second interspaces along the left sternal border and in the applica larrya ventricular impulses may heave or lift your fingers then check for thrills by pressing the ball of your hand firmly on the chest in these same locations.

If subsequent auscultation reveals a leveled murmur go back and check for thrills over that area again next identify the applica pulse the applicable impulse represents the brief early pulsation of the left ventricle as it moves anteriorly during contraction and touches the chest wall note that in most examinations the apical impulse is the point of maximal impulse or PMI however some pathologic conditions and enlarged right ventricle for example may produce a pulsation that is more prominent than the apical impulse using the polymer surfaces of several fingers then for finer assessments your finger tips followed by one finger palpate to confirm the characteristics of the apical impulse. 

You will notice location diameter and amplitude identify the location of the applica impulse by the interspaces in which you feel it and by its distance in centimeters from the mid sternal line if you experience difficulty in locating the apical impulse ask the patient to roll onto his left lateral side that is into the left lateral decubitus position palpate again using the polymer surfaces of several fingers if you still cannot find the apical impulse ask the patient to exhale fully and hold his breath for a few seconds measure the diameter of the impulse in centimeters feel for the amplitude of the apical impulse. 

It is usually small and feels like a gentle tap with experience you will learn to feel the apical impulse in a high percentage of patients however obesity a very muscular chest wall or an increased anteroposterior diameter of the chest may make the apical impulse undetectable next feel for a right of ventricular impulse at the lower left sternal border and in the epigastric or subxiphoid area while keeping one finger in the third interspace place additional finger tips in the fourth and fifth interfaces if the patient's chest has an increased anteroposterior diameter palpate for the right ventricular impulse high in the epigastric area where it may be easier to feel auscultation of heart sounds is an important skill that leads directly to several clinical diagnosis. 

Before auscultate in the heart let's review normal heart sounds closure of the heart valves creates a pair of audible heart sounds the first sound s1 arises from closure of the michael down my cuspid valve closure may also contribute to s1 the second sound s2 arises from closure of the aortic valve pulmonic valve closure may also contribute to s2 ventricular systole occurs between s 1 and s 2 then circular diastole occurs between s2 and the next s1 the fact that diastole usually lasts longer than systole is helpful in distinguishing the two sounds the abnormal sounds of s3 and s4 can be heard in early and late diastole when oscillating it's important to know your stethoscope the diaphragm is better for detecting higher pitched sounds. 

Such as s1 or s2 the murmurs of a or Tek and mitral regurgitation and pericardial friction rubs the Bell is more sensitive to low pitched sounds such as s3 or s4 and the murmur of mitral stenosis when auscultate in the heart remember to correlate your findings with the patient's jugular venous pressure and carotid pulse you will listen for s1 and s2 in each of the six listening areas in the aortic area in the right second interspace close to the sternum and the pulmonic area and the left second interspace close to the sternum and the left third interspace and the tricuspid area and the left fourth and left fifth interspaces and in the mitral area at the apex the auscultation sequence will start with the diaphragm of the stethoscope and progress from the base of the heart moving from the right second interspace to the left second interspace and down the left sternal border to the apex then with the bell of Assefa scope.

Physical Exam Cost 

We will listen along the lower left sternal border in the left fourth and fifth interspaces then we will listen at the apex adjust us stethoscope so that you'll be listening through the diaphragm begin listening in the aortic area at the right second enter space close to the sternum starting at the right second interspace helps orient you to the cardiac cycle note the cardiac rate and rhythm normally the rate is 60 to 100 beats per minute and the rhythm is regular identify s 1 and s 2 and listen for extra heart sounds and murmurs murmurs are covered in greater detail later in this video in the aortic area and also in the pulmonic area s 2 is usually louder than s 1 still listening in the aortic area but focusing more in the pulmonic area try to identify the inspiratory splitting of s2 into its two components its first component a 2 is from left-sided a or tick valve closure its second component P 2 comes from right-sided pulmonic valve closure this physiologic split of s2 a and s 2 P normally occurs during inspiration during expiration. 

However these two components are fused into a single sound s 2 let's listen again usually diminishes in intensity while s one becomes louder as you proceed down through the third interspace and into the tricuspid area listen at the apex here at the mitral area s1 is usually louder than s2 now switch to the bell of the toughest cope listen next along the lower left sternal border in the left fourth and fifth interspaces then listen at the apex to improve your ability to hear s3 s4 and the murmur of mitral stenosis place the patient in the left lateral decubitus position have the patient roll partway onto his left side this brings the left ventricle closer to the chest wall and makes low-pitched sounds more audible then recheck the position of the apical impulse and place the bell lightly over that location if the patient had an audible s3 it would sound like this now notice how the third heart sound disappears. 

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When the Bell is placed more firmly on the chest wall listen again with light pressure with firm pressure and once again with light pressure murmurs are differentiated from heart sounds by their longer duration if you detect a heart murmur you must learn to assess its timing shape location of maximal intensity and radiation grade its intensity and assess its pitch and quality palpating the carotid pulse as you listen can help you with timing first decide if you're hearing a systolic murmur falling between s1 and s2 and coinciding with the carotid up stroke or a diastolic murmur falling between s2 and s1 murmurs are classified according to where they fall in systole and diastole systolic murmurs can be early mid or late systolic or even pansystolic. 

For example a mid systolic murmur as heard in physiologic flow murmurs or aortic stenosis begins after s1 and stops before as to grief gaps are audible between the murmur and the heart sounds listen carefully for the gap just before s2 if present the gap usually confirms the murmur as mid-systolic not pansystolic a pansystolic murmur is heard with my four Gurjit ation starts with s1 and stops at s2 without a gap between murmur and heart sounds let's turn our attention next to diastolic murmurs and early diastolic as in a or decor agitation starts right after s - without a discernible gap. 

They usually fades into silence before the next s1 a mid diastolic murmur as in mitral stenosis starts a short time after s2 it may fade away as heard here or it may merge into a late diastolic murmur a late diastolic murmur as heard with mitral stenosis starts late in diastole and typically continues up to s-1 the shape of a murmur is determined by its intensity over time a crescendo murmur grows louder a decrescendo murmur grows softer a crescendo decrescendo murmur as heard with aortic stenosis first rises in intensity then falls a plateau murmur has the same intensity throughout the location of maximal intensity is determined by the site where the murmur originates find the location by exploring the area where you hear the murmur describe where you hear at best in terms of the interspace and describe the murmurs position relative to the sternum the apex or the mid sternal a particular or one of the axillary lines radiation also referred to as transmission from the point of maximal intensity reflects not only the site of origin. 

But also the intensity of the murmur and the direction of blood flow explore the area around a murmur and determine where else you can hear it intensity is usually graded on a six point scale at expressed as a ratio the numerator describes the intensity of the murmur wherever it is loudest and the denominator by convention is six indicating the scale you are using intensity is influenced by the thickness of the chest wall and the presence of intervening tissue using the six point scale grade one indicates a murmur that is very faint and heard only after the listener has tuned in it may not be heard in all positions a grade-two murmur is quiet. 

But heard immediately after placing the stethoscope on the chest a grade three murmur is moderately loud grades four five and six are increasingly loud and accompanied by a palpable thrill the pitch of murmurs is categorized as high medium the quality of a murmur is described in terms such as harsh as in a or text enosis blowing as in a or decree cogitation musical and rumbling as in mitral stenosis you should learn the characteristics of murmurs are running from each of a valve roll or lesions and then use these terms when you describe them for example a grade two over six harsh crescendo decrescendo mid systolic ejection murmur best heard in the second right interspace suggests a or text enosis to better detect the more subtle diastolic murmurs of aortic regurgitation and Mychal stenosis. 

Physical Exam Template

You should routinely use two maneuvers the first maneuver is performed with the patient's sitting up and leaning forward ask the patient to exhale completely and hold his breath out using the diaphragm of the safest oh listen at the left second interspace and down the left sternal border to the apex for the high-pitched soft blowing decrescendo diastolic murmur of aortic regurgitation pause periodically to allow the patient to breathe if the patient had this murmur it would sound like this the second maneuver for auscultate murmurs is to have the patient change to the lateral decubitus position as demonstrated earlier when auscultate in heart sounds this position enhances detection of the more subtle opening snap and diastolic rumble of mitral stenosis a clear well-organized clinical record employing language. 

That is neutral professional and succinct is one of the most important adjuncts to patient care for a healthy patient you're right up by the include language such as the jugular venous pressure is 3 centimeters above the sternal angle with the head of the bed elevated to 30 degrees carotid up strokes are brisk without brewery's the point of maximal impulse is tapping seven centimeters lateral to the mid sternal line into fifth intercostal space but s1 and s2 no murmurs or extra sounds to summarize examination of the cardiovascular system includes examination of jugular venous pressure and the carotid pulse an examination of the heart including inspection palpation and all skhul tation.

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