Transcript Clinical Medicine Review - UNT Health Science Center

Clinical Medicine Review
Respiratory
Cardiopulmonary
Peripheral Vascular
Pulmonary Vignette
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Types of Illnesses to expect:
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Pneumonia
Cough or Wheezing
Emphysema
Shortness of Breath
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Practice Vignette
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45 y/o white male with c/c fever, body
aches, cough with a rusty colored
sputum, and right sided chest “ache”
1st Welcome
2nd Set Agenda
3rd Open Ended? (Get more info)
4th Emotion Seeking ??
5th Transition
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6th- History of Present Illness
Don’t repeat the same stupid questions
Use skills like paraphrasing or echoing
to confirm info already given that is
relevant to OLDCARTS
Past Medical History
Don’t take a long time here because we
have not really learned this skill yet.
Make sure to hit the points that are most
important to the symptoms your patient
has.
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Past Medical History for Pulmonary
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Allergies (triggers)
Meds (Ace Inhibitors can cause cough)
Past Ilnesses- Pneunomia, Bronchitis,
Asthma, TB or exposure
Hospitalizations- Recent???? Nosocomial
Surg- Nahhhh
Injuries- Recent Trauma to Chest
Habits- SMOKING PACK YEARS
Family Hx- a1 Anti-trypsin, TB, smoking
Prev Med- Immunizations (Pneumococcal),
TB skin test ever??? Treated???
Social-Travel, exercise, occupation
(asbestos or smoke)
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PMH Mnemonic
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All
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My
Pals
Have
Sex
In
Hotels
For
Pretty
Socialites
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 Inspection
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With shirt off, look at and verbalize chest
diameter, respiratory rate and depth, nails
for clubbing, skin for cyanotic changes
You have to say out loud what you are
looking for and what you are finding even if
it is completely normal.
Example “ The patient displays a normal AP
diameter, no cyanosis, no clubbing,
respirations are 24 and slightly labored,
and intercostal accessory muscle usage is
seen”
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Palpation-
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the surface anatomy and landmarks
respiratory excursion
symmetry of expansion
TACTILE FREMITUS
Percussion-
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Diaphragmatic Excursion
cursory inflation of all lobes
Don’t forget to do anterior and posterior for
everything!!
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Auscultation-
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Can’t do it through clothing
use the diaphragm for the lungs
learn this phrase, “ Normal vesicular
breath sounds without any adventitious
sounds”
Bronchial over large bronchi
Bronchovesicular over branched bronchi
Vesicular over majority of parenchyma
Listen to all 5 lobes
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Lobar Anatomy Revisited
More Lobar Anatomy
Areas to Percuss, Auscultate, and
Assess Fremitus
Abnormal Breath Sounds
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Adventitious Sounds- wheezing, rales
(crackles), stridor, rhonchi
Things to check over areas where you
suspect consolidationBronchophony-when normal spoken word
is louder than normal over area
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Egophany-EEE to AAA over area
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Whispered Pectoriloquy- a whisper sounds
like a normally spoken volume
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Pulmonary PearlsMake sure to do a quick listen of the
heart with the bell and diaphragm even if
your symptoms are all pulmonary. If your
symptoms are borderline cardio, do the
cardio exam too.
Make sure to know where the right
middle lobe is because it is commonly
afflicted with CAP (community acquired
pneumonia)
TB is common in the lung apexes
Don’t feel compelled to diagnose
 Cardiac
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Vignette
A 62 y/o AA female c/c Chest Pain x 2
hours. She states that the pain is like
a pressure, and is 7/10. It moves into
her jaw and left arm as well. She had
similar pain on and off last year but it
would always come when she mowed
the yard. Then it would immediately
go away after she sat down. She takes
Insulin, Lipitor, and Captopril.
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Same PC interview
OLDCARTS (some given already)
PMH- focus on the info you are given
and expand upon it. Ask about family
history of CAD. Ask about recent
exertional event that could cause chest
wall soreness. Does it hurt to take a
deep breath? Has she ever had an MI?
Does she exercise? Diet..guess??, Last
Stress Test…nuclear?? SMOKER???
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Inspection-
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Heaves, Lifts, Scars (bypass), PMI, splinter
hemorrhages in the nails
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Palpation-
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PMI, Thrills, Heaves and Lifts, PAIN??
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Percuss-
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For heart borders basically to attempt to
evaluate for LVH. PMI used to confirm. The
PMI may be felt better with the patient on
their left side.
Auscultation
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Use the bell over the 5 sites
Use the diaphragm over the 5 sites
Verbalize what you are doing.
Example of what you might say, “ The
heart has a regular rate and rhythm at 60
bpm, no murmurs, no extrasytoles, a
normally louder S1 at the apex and S2 at
the base, and no pericardial rubs noted,
and there is a physiologic S2 split heard
in inhalation”
Auscultation Cont...
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Listen to all areas in the supine and
sitting position
Listen to the apex (mitral) with the
patient on their left side slightly to check
for the presence of a low pitched
diastolic murmur of mitral stenosis. Use
the BELL
Lean patient forward in exhalation to
check for high pitched diastolic aortic
regurgitation murmur (use diaphragm)
The Auscultation Points
Cardiac Pearls
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Always perform at least an auscultation
of the lungs at a minimum, but save it
for the end in case you run out of time.
At some point during cardiac
auscultation, palpate a peripheral pulse
and verbalize its character- bounding,
thready, normal strong upslope, and
note if they are tachy or brady.
Murmurs
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Of all the patients they will be using, at
least one will likely have a real murmur.
Don’t panic!!
Try and time the murmur to determine if it
is diastolic or systolic, and verbalize
where it is, what it sounds like (blowing,
rumbling etc..).
If you barely hear it in one or two spots, it
is probably a 2/6
Explain that this is your first murmur to
hear, but don’t avoid mentioning it.
Peripheral Vascular System
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Vignette:
A 64 y/o Hispanic female c/c right lower
leg swelling and pain since awakening
yesterday. She just got back from a trip to
Mexico. She is a smoker, takes Prempro
(HRT), and uses a diuretic for swelling in
her feet from time to time. She started
having some shortness of breath an hour
prior to her arrival at the office.
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HPIOLDCARTS
Some of the information was already
obtained in the c/c and intro
PMHAsk about recent surgeries,
prolonged periods of immobility,
medications, pack years of smoking,
lipid history, family history of
vascular disorders, injuries to the
legs, pain with walking.
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Inspection-
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observe for obvious swelling, edema, color
of skin, hair distribution distally, nail health.
Inspect jugular venous pulsation and
column height at 45 degrees, and
differentiate it from carotid pulsations
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Palpation-
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pulses in the carotid*, femoral, radial,
popliteal, and dorsalis pedis and posterior
tibial arteries. Is it regular? 0-4 scale with 4
being bounding and 2 being normal.
Always check pulses bilaterally one after
the other, and assess temperature of skin
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Auscultate-
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*For carotid bruits prior to palpating the
pulse
check for aortic, renal, and femoral bruits
check for a pulsatile abdomen (deep)
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Measure the BP-
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palpate the systolic pressure first to avoid
the ascultatory gap
measure in both arms at heart level
record all 2 or 3 Korotkoff sounds
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Special Tests and Considerations-
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Allen’s Test for radial/ulnar artery
capillary refill for circulation
edema graded 1-4
varicosities, cords, tender superficial veins
Homan’s sign to r/o DVT
Tape Measurement of calf and thighs
DVT would produce pain, redness, swelling,
induration, edema.
10% of DVT’s will get a ??????
Measure radial vs. femoral pulse on one
side to determine if coarctation of the aorta
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