Clinical Medicine Review

1
Clinical Medicine Review

• Respiratory
• Cardiopulmonary
• Peripheral Vascular

2
Pulmonary Vignette

• Types of Illnesses to expect
• Pneumonia
• Cough or Wheezing
• Emphysema
• Shortness of Breath

3
Practice Vignette

• 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

4

• 6th- History of Present Illness
• Dont repeat the same stupid questions
• Use skills like paraphrasing or echoing to
  confirm info already given that is relevant to
  OLDCARTS
• Past Medical History
• Dont 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.

5

• Past Medical History for Pulmonary
• 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)

6
PMH Mnemonic

• All
• My
• Pals
• Have
• Sex
• In
• Hotels
• For
• Pretty
• Socialites

7

• Inspection
• 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

8

• Palpation-
• the surface anatomy and landmarks
• respiratory excursion
• symmetry of expansion
• TACTILE FREMITUS
• Percussion-
• Diaphragmatic Excursion
• cursory inflation of all lobes
• Dont forget to do anterior and posterior for
  everything!!

9

• Auscultation-
• Cant 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

10
(No Transcript)
11
Lobar Anatomy Revisited
12
More Lobar Anatomy
13
Areas to Percuss, Auscultate, and Assess Fremitus
14
Abnormal Breath Sounds

• Adventitious Sounds- wheezing, rales (crackles),
  stridor, rhonchi
• Things to check over areas where you suspect
  consolidation-
• Bronchophony-when normal spoken word is louder
  than normal over area
• Egophany-EEE to AAA over area
• Whispered Pectoriloquy- a whisper sounds like a
  normally spoken volume

15

• Pulmonary Pearls-
• Make 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
• Dont feel compelled to diagnose

16

• Cardiac 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.

17

• 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
  Testnuclear?? SMOKER???

18

• Inspection-
• Heaves, Lifts, Scars (bypass), PMI, splinter
  hemorrhages in the nails
• Palpation-
• PMI, Thrills, Heaves and Lifts, PAIN??
• Percuss-
• 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.

19
Auscultation

• 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

20
Auscultation Cont...

• 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)

21
The Auscultation Points
22
Cardiac Pearls

• 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.

23
Murmurs

• Of all the patients they will be using, at least
  one will likely have a real murmur. Dont 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 dont avoid mentioning it.

24
Peripheral Vascular System

• 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.

25

• HPI-
• OLDCARTS
• Some of the information was already obtained in
  the c/c and intro
• PMH-
• Ask 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.

26

• Inspection-
• 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
• Palpation-
• 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

27

• Auscultate-
• For carotid bruits prior to palpating the pulse
• check for aortic, renal, and femoral bruits
• check for a pulsatile abdomen (deep)
• Measure the BP-
• palpate the systolic pressure first to avoid the
  ascultatory gap
• measure in both arms at heart level
• record all 2 or 3 Korotkoff sounds

28

• Special Tests and Considerations-
• Allens Test for radial/ulnar artery
• capillary refill for circulation
• edema graded 1-4
• varicosities, cords, tender superficial veins
• Homans sign to r/o DVT
• Tape Measurement of calf and thighs
• DVT would produce pain, redness, swelling,
  induration, edema.
• 10 of DVTs will get a ??????
• Measure radial vs. femoral pulse on one side to
  determine if coarctation of the aorta