3/28/2017 1 If you only have 5 minutes… PHYSICAL ASSESSMENT PEARLS Barb Bancroft, RN, MSN, PNP The patient history • The most important part of any patient assessment is the patient history… • Components of the history are numerous, but remember, since you ONLY have FIVE minutes, a detailed 2‐hour history is not possible • Pick and choose the parts of the present and past history that are relevant to their current problem For example… • Someone with new onset muscle aches and pains on a statin drug vs. someone who starts a statin drug but has had muscle aches and pains for 15 years • New onset cough since the drug lisinopril was prescribed for hypertension, or has the patient had the cough for 16 years
Transcript
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If you only have 5 minutes…PHYSICAL ASSESSMENT PEARLS
Barb Bancroft, RN, MSN, PNP
The patient history
• The most important part of any patient assessment is the patient history…
• Components of the history are numerous, but remember, since you ONLY have FIVE minutes, a detailed 2‐hour history is not possible
• Pick and choose the parts of the present and past history that are relevant to their current problem
For example…
• Someone with new onset muscle aches and pains on a statin drug vs. someone who starts a statin drug but has had muscle aches and pains for 15 years
• New onset cough since the drug lisinopril was prescribed for hypertension, or has the patient had the cough for 16 years
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What is the patient telling you in his/her own words?
• “I’ve had a terrible cough for 3 weeks…”
• “I can’t catch my breath…”
• “I am having awful pain in my chest…”
• “My head feels like it’s going to explode…”
WATCH the patient as you are taking the history• Body language
• Facial expressions
To characterize the “chief complaint” start with the
PQRSTmnemonic
• P—Precise location? Where?
• Pinpoint the location? Show me…
• Precipitate the problem? What were you doing when it started?
• Palliate the problem? Did anything help?
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To characterize the “chief complaint” start with the PQRST mnemonic
• Quality of the pain?
Help them out with this one…is it deep, burning, lancinating (shooting), cramping, crushing, vice‐like, sharp, dull, explosive…
• Quantity of the (blood, vomit, sputum)?
• Estimated volumes: Teaspoon = size of your first thumb joint; 1 “Dixie” cup = 75 mL; 1 coffee cup = 225 mL; 1 cola can = 350 mL;
To characterize the “chief complaint” start with the PQRST mnemonic
• Radiate? Where does it go? Up the jaw? Down the arm? One side of the head? To the back? Down the back of the leg? To the groin?
• Referred pain? Embryologic origins of pain
Referred pain
• Embryologic origins
• The diaphragm starts in the neck and is supplied by cervical cord segments C3,4 (The phrenic nerve)—to supply your gills
• Shared afferents with the shoulder/neck area of skin
• Gills close up—diaphragm moves to the area between the thorax and abdomen; pulls the phrenic nerve with it
• Anything that causes diaphragmatic irritation can refer the pain to the shoulder
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What causes diaphragmatic irritation?
• Above the diaphragm (pneumonia, cardiac) and below the diaphragm (spleen, liver, gall bladder, ectopic pregnancy)
• Lower lobe pneumonia
• Fever (greater than 37.8), tachypnea (greater than 22) in the geriatric patient, confusion, and shoulder pain = pneumonia in the elderly
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The fancy dermatome chart from textbooks• Area of skin supplied by a posterior (sensory) spinal cord segment—
• Shared afferents with visceral organs
• dermatomes T1‐T4—shared with myocardium, pericardium, aorta, pulmonary artery, esophagus…maximal intensity of pain is retrosternal/precordial area, up neck and down arm
MY dermatome chart…
• C3,4 (shoulder* and referred pain)
• T4 (nipple)• T10 (umbilicus)
• L1 (bikini underwear)• L2 (thigh)• L3,4 (knees)• S1,2 (back of the leg)‐‐sciatica
• S3‐5 (perineum)(anal wink)
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Herpes simplex –Sacral 3,4, &5
• Herpes “genitalia”
• Enters via mucous membranes below the belt –lives in sacral nerve dorsal roots (S3‐S5)
• “Hey nurse, can I get hairpiece from a toelet seat?”
Sensory innervation to the face—cranial nerve V (trigeminal)—V1, 2, 3
To characterize the “chief complaint” start with the PQRST mnemonic
• S—what is the Severity of the pain?
• Adults? 1 to 10 with 1 being the least painful and 10 being the most painful
• Peds? Smiley to “frowney” faces
• BODY LANGUAGE
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Pain severity in patients with Shingles (Herpes Zoster, Hell’s Fire)
• The research scale used is from 1‐100 instead of 1 –10
• Patients with reported scores greater than 40 are considered to have severe pain
To characterize the “chief complaint” start with the PQRST mnemonic
• T—what is the Time frame or Temporal sequence?
• Clarify which symptom came first and the order in which others follow. Temporal relationships between associated symptoms are also most helpful.
• Did the nausea and vomiting precede the abdominal pain or did the abdominal pain come first followed by nausea and vomiting? If N & V first, consider gastroenteritis; if pain then N & V, it could be acute appendicitis in patients over age 13 with abdominal pain
Time or Temporal sequence
• Did the pain last for an hour, 15 minutes, 5 minutes, or less than 5 minutes? Or off and on for 5 years?
• Acute appendicitis usually presents within 24 hours of the abdominal pain
• Symptoms persisting for years are unlikely to be caused by a catastrophic infection, cancer, or other illness
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Temporal sequence and an ischemic stroke• Patients may wake up with a “stroke in progress…”
• You have a 3 to 4.5 hour “window” to give tissue plasminogen activator (alteplase) in patients having an ischemic stroke
• You need to know WHEN the stroke symptoms started?
• “When did you last see your husband as normal?”
• Bed at 11? Woke up at 7 with symptoms?
• Bed at 11? Woke up at 5, perfectly fine to go to the bathroom? Woke up again at 7 with symptoms?
The AAA’s…Associated symptoms , Absent symptoms or events or ALARM symptoms‐‐
• What else can you tell me about your problem?
• Asking and CHARTING associated signs and symptoms as well as ABSENT signs and symptoms
ALARM SIGNS
• Headache every morning when awakening vs. headache every afternoon when the kids get home from school
• Chronic cough with hemoptysis and weight loss
• Chest pain with nausea and diaphoresis
• GERD with unexplained weight loss
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Chief complaint… “Severe chest pain for 25 minutes”—first thought? Is this an acute coronary syndrome?
• FIRST ACTION: Any patient with a suspected acute coronary syndrome should chew 160‐325 mg of ASA;
• this one simple therapy is associated with a 35‐day mortality reduction exceeding 20%
• 13% of patients in the Emergency Department with acute chest pain are having an acute coronary syndrome
• Only 1.5% seen in the primary care setting are having an ACS
• Now, think…what structures are located in the chest and how should I go about considering this specific patient with chest pain?
• Neurologic—herpes zoster (“band‐like” pain may precede vesicular eruption)
• Psychological—panic disorder, depression
• *Musculoskeletal conditions account for 29% ‐36% of patients presenting to primary care facilities with the chief complaint of chest pain‐‐also associated with high anxiety rates (54%‐93%)
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Is it ACS? The following features help narrow the DX• HIGH LIKELIHOOD
• Chest pain radiating to one or both arms
• Chest pain associated with exertion, N, V, diaphoresis
• Chest pain described as pressure or as “worse than previous angina or similar to previous MI”
• (Cayley WE, Clinician Reviews, September 2014)
Is it ACS? The following features help narrow the DX• LOW LIKELIHOOD• Stabbing, pleuritic, or positional chest pain• Pain in an inframammary location• Pain NOT associated with exertion• Pain IS reproducible with palpation*(*The most helpful sign or symptom in evaluating a patient with chest pain is chest wall tenderness on palpation, which largely rules out ACS in low‐prevalence settings)
• Cayley WE, Clinician Reviews, September 2014)
So, use the PQRST + AA
• Start with the P’s…Pinpoint the pain, what is the precise location? WATCH THE PATIENT
• LEVINE sign…clenched fist held over sternum is pretty classic for angina or an MI
• Swooping the hand from the back, under the axillary region and to the front may indicate a neuropathy
• Moving the fingers up and down from the bottom of the sternum to the top may indicate heartburn/GERD
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What precipitated the pain?
• Exertion? What were you doing when the chest pain started? How long did it take before the chest pain started? Shoveling snow? Raking leaves? Usually a 5‐minute delay (Lag time) for cardiac pain. Did the pain start as soon as you picked up the shovel or the rake? Did you just have a fight with your boss? Did the pain start during sex?
• Digression: Can you have a heart attack during sex?
Only if…
• ONLY IF YOU’RE HAVING SEX WITH SOMEONE YOU SHOULDN’T BE HAVING IT WITH!!!
• Usually NOT if it’s your same old, same old partner…
• (Only 1% of all ACSs are during sex; 75% are when husbands are having an extramarital affair)
First question for any male (from 20 to 120 years old) with chest pain…(whether it’s during sex or not)
• When was your last dose of an erectile dysfunction drug?
• Sildenafil (Viagra)(24)
• Tadalafil (Cialis)(36‐48)
• Vardenafil (Levitra)(24)
• Avanafil (Stendra)(24)
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Remember…
• The combination of an ED drug with a nitrate can be deadly
• Tell the whole truth, nuttin’ but the truth!!
• “Two hours ago, but don’t tell my wife…”
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Back to the P’s
• What palliates the pain?
• Stopping the activity? How long did it take before the chest pain stopped when you ceased the activity? (5‐minute lag time with cardiac ischemic pain)
• Did you put a little white pill under your tongue? If so, how many and how long did it take for the pain to stop?
• Did you take an antacid?
Quality or Quantity
• What is the Quality of the pain? Throbbing, burning, shooting, squeezing, crushing, “vice‐like”, “elephant sitting on the chest”?
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Radiate/Referred
• Where does it Radiate? Front, back, side, down arm, both arms, up to the jaw?
• Is it Referred pain?
Severity
• What is the severity of the pain…
• On a scale from 1‐10, with 1 being the least and 10 being “outta control”—where do you rank pain on this scale?
• Angina 5 or 6
• MI—9 or 10 or greater
Timing or Temporal sequence
• Temporal sequence; Timing
• When did it start?
• How long did it last?
• How often do you experience this type of pain?
• What’s unique about the time of day and an acute coronary syndrome? An MI in the a.m. causes more damage than any other time of day…‐‐20% more tissue death between 6 a.m. and 12 noon than any other time of day (proteins called salvage kinases usually protect the heart from damage...less salvage kinases produced in the a.m. – Ibanez B. Heart DOI:10:1136/hrt.2010.212621)
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ADDITIONAL SIGNS
• Any additional symptoms?
• Sweating? Nausea? Fatigue?
• Dizziness? Light‐headedness
• The feeling of impending doom…
GENDER and AGE CONSIDERATIONS
• 38 y.o. female with chest pain?
• Quick questions to rule OUT a myocardial infarction in a young woman…what is her risk of having an MI at age 38?
• Diabetes• Birth control pills? Obesity? Surgical menopause?
• Autoimmune disease? SLE, RA, vasculitis
• Methamphetamine, cocaine
• Family history
• Is she a smoker?
What about a…
• 38 y.o. male with chest pain? Family history? Illicit drugs?
• 70 y.o. female with classic chest pain? Most likely an ACS due to age…onset of menopause?
• 58 y.o. diabetic male (28 yr hx of DM) without chest pain but with sweating, nausea, tachycardia, hypotension and the feeling of impending doom? Assume heart attack until proven otherwise…silent ischemia due to vagal neuropathy
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The evaluation of chest pain in women
• Heart attack warning signs for women—instead of crushing pain in the chest (40% DON’T have crushing chest pain), they may have:
• Fatigue or extreme tiredness
• SOB• N & V, cold sweats, Flu‐like symptoms
• Flushing, dizziness• Jaw, abdominal, elbow or inter‐scapular pain
• Symptoms that last for hours or days or even a month before the myocardial infarction
CORONARY ARTERY DISEASE and MEN
• The studies on heart disease were all done in VA hospitals 50 years ago…
• Hello?
• Sexual bias? White men, 176 pounds, 45‐ years‐old
Medical History? How much time do you have? What is relevant to current episode?
• Allergies—drugs, bugs, food?
• Drug list—prescription, OTC, illegal, (borrowed from friends)
• Prior surgeries or illnesses (but only if related to current episode) Ex. CABG or coronary stent IS relevant in a patient with chest pain…
NEW IMPORTANT QUESTION: Ask women about cancer hx—drugs/radiation used to treat breast/chest cancers are cardiotoxic
• Family history
• Social history (if an STD is relevant)• Smoking and drinking
• Dietary history
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DIGRESSION on EVIDENCE‐BASED physical findings
• *LR is the Likelihood Ratio that this sign or symptom occurs with the disease or condition—the higher the LR, the greater the association
• The number 1 is assigned to any sign or symptom for any condition‐‐
EXAMPLE #1: LRs and the diagnosis of cirrhosis of the liver
LR ratios predicting the the presence of peripheral vascular disease
• Absence of both pedal pulses (LR 14.9)
• Presence of any limb bruit (LR 7.3)
• Presence of wounds or sores on the feet (LR 7.0)
• Absence of the femoral pulse (LR 6.1)
• Presence of asymmetric coolness of the foot (LR 6.1)
• McGee S. Evidence‐Based Physical Diagnosis. WB Saunders, Co. 2012
What did I learn in Nursing school (1972)?• Major findings for PAD were:
• Shiny atrophic skin (LR 1.7)
• hairless lower limbs (LR 1.7)
• prolonged capillary refill time ≥ 5 seconds (LR 1.9)
• WORTHLESS!!
Temperature
• A rise of greater than 1.5° C within 2 hours—consider sepsis in the GERIATRIC PATIENT
• Patients on neuroleptic drugs (central dopamine blockers) such as haloperidol and/or the atypical antipsychotics*, tend to have lower basal temperatures (always complaining of “feeling cold”)—baseline temperature can be lower than 1.5⁰ lower than normal…therefore a “fever” in these patients may exhibit a normal temperature
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The treatment of fever
• Use one or the other (exception??)• Acetaminophen is preferable for any viral illness
• Acetaminophen (10‐20 mg/kg PO q 4‐6 hours—do NOT exceed 5 doses in 24 hours)(71minutes to work to reduce fever)
• Ibuprofen 5‐10 mg/kg, every 4 hours (works faster, decreases inflammation) (44 minutes to work)
• We don’t use aspirin anymore for fever reduction but just in case you’re wondering, it only takes 35 minutes to lower the temperature
Speaking of acetaminophen
• It’s worthless for osteoarthritis. PERIOD.
• NEED I SAY MORE?
• daCosta BR, et al. Effectiveness of NSAIDS for the treatment of pain in the knee and hip osteoarthritis: a network meta‐analysis. Lancet,May 21, 2016; 387(10033):2063‐2162.
Heart rate
• Unexplained tachycardia (greater than 100)—consider hyperthyroidism, dehydration, atrial fibrillation, heart failure, autonomic neuropathy with the loss of the vagus nerve in diabetics (results in silent ischemia); fever increases heart rate; anxiety
• Bradycardia (less than 55)—hypothyroidism, digoxin, AV block, beta blockers (“olols, alols, ilols”), calcium channel blockers such as verapamil and diltiazem
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Heart rate, pulses
• Important to take a pulse for at least 30 seconds for patient with an arrhythmia, but a full minute is more accurate
• With a 15‐second pulse you’ll be off by 4 beats and with only a 10‐second pulse you’ll be off by at least 6 beats
• Need to take the heart rate for a full minute if you are basing the administration of a drug based on heart rate
**distinctive because other causes of tachypnea (heart and lung disease), reduce vital capacity and cause rapid, shallow respirations
Blood pressure
• What is ideal? 120/80
• May be slightly higher (systolic up to 150*) in the elderly to avoid hypotension, fainting, and a broken hip (especially in diabetics on hypoglycemic meds)
• Keeping the blood pressure BELOW 150/90 prevents strokes, MIs, renal failure and DAT
• *CONTROVERSIAL—new study demonstrated benefit of a lower systolic BP of 120 for older patients (mean age 68) w/ risk factors for heart disease—lowered all‐cause mortality and less heart failure) BUT…serious episodes of hypotension, electrolye abnormalities, and AKI)
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Some medications and physical assessment pearls
• Beta blockers (“olols, alols, ilols”)—cold feet, hair loss (50% loss to become noticeable),, decreased heart rate (10‐15%), exercise intolerance
• Thiazide diuretics—electrolyte imbalances leading to confusion/delirium (especially hyponatremia and hypokalemia)
• Amiodarone and lithium decrease thyroid function and can cause constipation (two other important considerations in the elderly in addition to all of the obvious—hypothyroidism and Parkinson’s disease)
• Confusion? Lots of drugs…
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Physical exam
• My left ankle is swollen, my right ear hurts…
• RULE OF THUMB…always examine the “good” side first
• Left ankle? Examine the right ankle…
• Right ear? Look at the left ear…
• Neuro exam – symmetry is the rule; check from “side‐to‐side”
Inspection
• In most instances, look (inspect) and feel (palpate) before you listen...exception is the abdominal exam—look, listen, and then palpate
• Inspect the area to be examined—are there lesions, lumps, bumps, pulsations, color changes
Skin
• Generalized changes—turgor for hydration status (elderly—loss of extracellular water, loss of collagen AND loss of skin elasticity)
• Peripheral “tenting” is common
• Check for hydration with pinching the forehead or over the sternum
• Shrunken eyeballs
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Skin
• Hemochromatosis –Lifelong accumulation of iron, but the injury caused by excessive iron is slow; hence symptoms usually appear in the fifth to sixth decades of life
• “bronze” skin; Diabetes in 75% to 80% of the cases
• Known as “bronze diabetes”
Skin
• Jaundice – skin and sclera (sublingual area and soft palate first)
• Bilirubin level for jaundice—serum bilirubin > 42.8 ‐‐51.3 μ/L
Skin
• color (increased pigmentation, decreased pigmentation, patchy (vitiligo)—? autoimmune disease—also associated with Grave’s disease
• xanthelasmas (yellow plaques on the upper and lower eyelids) – high risk of CV disease (Christofferson M et al. BMJ 2011 Sep5)
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Signs and symptoms‐‐Hypothyroidism
• Dry hair, balding, loss of lateral third of eyebrows (Queen Anne’s eyebrows); enlarged tongue, scalloped edge of tongue
• Check pulse‐‐bradycardia (thyroid hormone and the number of receptors on the SA Node)
• bradypnea
• “dull” look
• Constipation
• Myxedema coma—you don’t have to be in a coma…
Skin changes – anemia
• The skin and mucous membranes may be pale if the hemoglobin is less than 80 – 100 g/L (8‐10 g/dL)
• Focus on the areas where vessels are close to the surface such as the mucous membranes, nail beds, and palmar creases
• If the palmar creases are lighter in color than the surrounding skin when the hand is hyperextended, the hemoglobin level is usually less than 80 g/L (8 g/dL)
Many causes of anemia—check the MCV• Iron deficiency anemia—women (periods and pregnancy)(1 TAMPON – 5 ml (1‐7 nl; 9‐12 excessive), growing kids (vertical growth), excessive tea drinking, bleeding (overt and occult) (MCV—normal/low)— celiac disease
• Thomas L et al. Semiological value of ABCDE criteria in the diagnosis of cutaneous pigmented tumors. Dermatology. 1998;197:11‐17.
Cardiovascular exam
• “Do not be in a hurry to listen to the heart. The most important sounds you will hear are the words of the patient as he presents the history…” Burnside JW.
Physical Diagnosis, 17th edition.
Overview: Find your lines and your spaces…orientation to structures
• Suprasternal notch
• Clavicle (1st rib is under the clavicle—non‐palpable)
• 2nd rib—first palpable rib
• 2nd ICS R and L (aortic and pulmonic area)
• 4th ICS parasternal border
• 5th ICS on L (apical/mitral) area)
• Epigastric area
• BASE vs. APEX
• LINES—MSL, MCL, AAL
• Dextrocardia
• Situs inversus –everything switched
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Cardiovascular exam ‐‐inspection
• 5th L ICS @ MCL for apical impulse—mitral area (aka apical area)
• Left 4‐5th parasternal border for the R ventricular area (tricuspid valve)
• 2nd R ICS—aortic area (aortic valve)
• 2nd L ICS—pulmonic area (pulmonic valve)
• Suprasternal notch—pulsation?
• Epigastric area—pulsation? (next slide)
Palpation
• Identify the apical impulse @ 5th ICS, MCL—should be no bigger than 1‐2 cm in size; gentle, brief contraction (only present in 50% of the population—turn patient on L side to feel)—if >4 cm consider a dilated heart)
• Is there a pulsation in the epigastric area? Beating up against the pads of your fingers? Aortic aneurysm? >5.5 cm in males and >5 cm in females—consider surgery; 85% are located beneath the renal arteries
• Beating against fingertips? Right ventricular hypertrophy…
Palpation…
• The base of the heart 2nd ICS’s…any thrills? Cat purring…
• A thrill with a heart murmur means that the murmur is at least a grade 3 (out of 6)
• Think valvular disease—aortic and pulmonicstenosis in 2nd R and L ICS
• The 5th L ICS at the MCL (apical or mitral area)
The apical area—mitral stenosis
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Jugular vein distention and heart failure…• Always check the R jugular vein in elderly(direct route to heart; L veins cross the mediastinum where the aorta may compress and falsely elevate).
• If top of neck veins are elevated> 3 cm above sternal angle check for other signs of heart failure
• Hepatomegaly, peripheral edema, S3 gallop
Abdominojugular reflex—more reliable than jugular vein distention as a test for heart failure
• The pressure applied over the abdomen shifts blood into the thorax and right atrium
• If the right ventricle is unable to handle this increased load, the result is a sustained increase in JVP.
• Compression of the liver is unnecessary• Compression of the peri‐umbilical area will suffice• Positive with a sustained increase in the JVP greater than or equal to 4 cm.
• LR ratio of 8 for detecting elevated left diastolic pressures
Pitting ankle edema—heart failure and drugs
• Subjective grading 1+‐4+
• 1+ slight pitting
• 2+ deeper but no detectable distortion of tissue
• 3+ noticeably deep, extremity full and edematous
• 4+ very deep pit, dependent extremity is grossly distorted
• Bilateral edema as a side effect of drugs that retain water or that are potent vasodilators—NSAIDS and Ca+ channel blockers
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Now it’s time to listen‐‐Notes on the stethoscope• Ear plugs that fit—block out extraneous noise
• Length of tubing no longer than 12”, but 8” is ideal• Any stethoscope of a pastel color is worthless• Do not listen over clothes• The bell—LOW‐pitched sounds; the diaphragm—HIGH‐pitched sounds
• Hold the bell “gently” against chest wall; it’s ok to “smash” the diaphragm
• Quiet room—no TV; no visitors; no wives, husbands, lovers, children; no construction
Where to listen? The usual suspects…aortic, pulmonic, mitral (tricuspid)
Positioning the patient…
• Sitting up and leaning forward—brings base of heart closer to chest wall
Murmurs of the aortic (2nd R ICS @parasternalborder) and pulmonic valves (2nd L ICS @parasternalborder) heard best in this position—high‐pitched systolic sounds (aortic stenosis)
• Left lateral recumbent (roll onto left side) brings the apex closer to the chest wall—best position to hear low‐pitched filling sounds during diastole (mitral stenosis) in the apical/mitral area (5th L ICS @ MCL)
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BUT, if you only have a minute…
• …and the patient is NOT a cardiac patient—you can just listen to the apical or mitral area—5th ICS @ L MCL
• Use the bell to pick up any low‐pitched murmurs
• “bell‐low”
If you have two minutes and you know the following…
• #1 diseased valve of the heart? MITRAL
• #2 diseased valve of the heart? AORTIC
WHERE WOULD YOU LISTEN FOR EACH OF THE ABOVE?
• #1 – 5th L Intercostal space @ MCL
• #2 – 2nd R Intercostal space @ parasternal border
Heart sounds—S1, S2
• S1 is the closure of the mitral and tricuspid valves—the END of diastole or filling of the heart; the aortic and pulmonic valves open signaling the beginning of systole)
• S2 is the closure of the aortic and pulmonicvalves—the END of systole or ejecting the blood; the mitral and tricuspid valves open signaling the beginning of diastole)
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Listening to heart sounds…
So what’s an S3?• Heard immediately after the S2…Lub, dub dub
• “gallop”
So…when you hear an extra heart sound…ie, murmurs• First decide if it’s in systole or diastole?
• 50% of all murmurs are systolic…therefore,
50% of all murmurs are diastolic. DUH…
Is the murmur after the LUB? Systolic?
Is the murmur after the DUB? Diastolic
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Characterizing a murmur…
• Timing—systole or diastole
• Duration—early, mid, late, continuous in relation to S1 and S2
• Pitch—low (bell), medium (equally heard), high (diaphragm)
• Intensity—1 through 6 (4‐6 usually assoc. with a palpable thrill)
• Quality—descriptive (harsh, blowing, soft)
• Location—where best heard
• Radiation‐‐where else is it heard (neck, axilla)
NOTE: stenotic valves cause a murmur when the valve is OPEN (blood shooting through a “tighter” valve)
The two most common stenoticmurmurs• mitral stenosis (diastolic) and aortic stenosis (systolic)(stenotic valves cause a murmur when the valve is normally OPEN)
• Mitral stenosis—low‐pitch, mid‐diastolic, (between S2 and S1) apical rumble (with a healthy mitral valve you can slip three fingers through the valvular opening; with a stenotic valve it’s tough to even slip a pencil through the valvular opening)
• Aortic stenosis—high‐pitch early systolic (between S1 and S2) ejection murmur (common in the elderly—2nd
most common cardiac surgery is to replace the aortic valve in the geriatric patient)
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The common regurgitant murmurs
• NOTE: regurgitant valves cause a murmur when the valve should be closed (mitral valve is CLOSED during systole or ejection; aortic valve is CLOSED during diastole or filling)
• Crackles – discontinuous sounds: “pulling apart strips of velcro”, “rubbing strands of hair together”; loudest at the base of the lungs (even if lung disease is distributed diffusely)
• Coarse—loud, low‐pitched and fewer in number per breath (originate in the larger airways)(clear with coughing) –bronchitis (used to be called rhonchi)
• Fine—soft, higher‐pitched (don’t clear with coughing)—pneumonia, COPD
• Early inspiratory crackles—appear early during inspiration and do not continue beyond mid‐inspiration; Crackles that continue past mid‐inspiration are called late inspiratory crackles
Auscultation for adventitious sounds…
• The finding of early inspiratory crackles (re‐opening of closed alveoli) greatly increases the probability of COPD (LR = 14.6); Most patients with early inspiratory crackles have severe obstruction (LR = 20.8)
• a FEW late inspiratory basilar crackles are very common in the very old patient (over 85)—aging process, loss of elastic recoil, not disease (only heard with a few deep breaths—re‐expanding alveoli in bed‐ridden adults, elderly, persons just aroused from sleep)
Good to know…
• Pneumococcal pneumonia—the cough usually resolves within 8 days
• Crackles heard on auscultation clear within 3 weeks—
• The chest X‐ray usually clears within four weeks in patients younger than 50 without underlying pulmonary disease
• Resolution may be delayed for 12 weeks or longer in older individuals and those with underlying lung disease
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Wheezing…
• Wheezing—sounds like a high‐pitched whistle; edema of airways; inspiratory wheezes? Expiratory wheezes?
• Asthma‐‐mild—end‐expiratory wheezes only; moderate—wheezing during entire inspiration and expiration; severe asthma attack—breath sounds becoming inaudible)
• Best pulmonary function? 3‐5 in the afternoon (after school)
• Worst pulmonary function? 3‐5 in the early a.m.• Most asthma deaths occur between 4 and 6 a.m.• GERD triggers bronchoconstriction—nighttime GERD can trigger asthma symptoms and cough
Apical TB
• Secondary or reactive TB
• Who’s at risk?
• What are the cardinal symptoms of TB?
• Where should you listen with your stethoscope?
• Post‐tussive inspiratory crackles
GI and GU exam
• Divide the abdomen into 4 quadrants?
• RUQ• LUQ• RLQ• LLQ• + the epigastric region between the rib cage
• + midline pelvic structures
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GI, GU exam—4 quadrants/ 3D
• Epigastrum—head of the pancreas (tail of the pancreas in upper left quadrant angled towards the back)(cancer of the head of the pancreas causes obstruction of the bile duct; cancer of the tail of the pancreas with back pain—won’t lie on their back)
• RUQ—80% of liver, gallbladder, second and third portion of the duodenum
Evaluation of the patient with the acute abdomen• While obtaining a history, palpate the abdomen; if it exhibits board‐like rigidity* with involuntary guarding, or you have palpated and/or observed a palpable, pulsating mass (just slightly to the left of the umbilicus), call your ever‐so‐friendly surgeon for immediate consultation
• *A note about the abdominal exam in the elderly—may not have “board‐like” rigidity even with a catastrophic event in the abdomen (reduction in muscle mass/rectus abdominis muscle “disappears”)
Acute appendicitis—major cause of the acute abdomen
• Consider from ages 2 to 92
• Acute appendicitis presents initially with peri‐umbilical pain and subsequently localizes to the right lower quadrant; n & v after pain starts in adults
• Median time from onset of sx to presentation is 24 hours or less
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A few more notes on acute appendicitis• Harder to dx the very young
• Perforated appendix—more common in young kids (80‐100% in kids under 3); 6.9% in the 20s;
• CT scan/ultrasound are the usual methods of diagnosis today but if you don’t have one…
• Possible peritoneal signs—rebound tenderness; Markle sign—drop from standing on toes to heels with a jarring landing or hop off the bed; smack ‘emon the bottom of the feet when supine; rectal exam
• Push one arm down—proprioception (parietal lobe)
The two‐minute neuro exam
• With eyes closed, ask patient to touch nose with outstretched hand—can the patient light on an object? any tremors‐‐‐checking cerebellar function and basal ganglia (tremors arising from both structures)—tremor of intent (cerebellar) vs. essential tremor (basal ganglia)
• Ask patient to walk across room and back—gait? Arm swing? Wide‐based? Stiff‐legged?
• cerebellar—wide based, staggering; MS, Booze, toddlers, Down syndrome)
• basal ganglia—shuffle, small steps, no arm swing; (Parkinson disease); athetoid, toe‐walking (Wilson’s disease, CP)
• 50% of the elderly population have lost their Achilles' reflexes
• Symmetrical loss?
• Unilateral loss with shooting pain down the leg? Herniated disc at L‐4,5
Babinski sign/reflex
• The Babinski reflex• Babinski, Josef Francois Felix, (1857‐1932), a Parisian of Polish origin, described the famous abnormality of the extensor plantar response seen in disorders involving the corticospinal tracts in a series of short articles beginning in 1896.
• English physicians used their “Rolls Royce” key
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The Babinski (1896) response• Is it present (sign of upper motor neuron disease) or is it absent ( do NOT use terms positive or negative)
• How to do? A slow (5‐6 second) hockeystick stroke beginning at the lateral plantar surface using a wooden applicator stick, key, or pointed handle of the reflex hammer
• The big toe dorsiflexes (goes up)
• Babinski pointed out that fanning of the toes is a normal phenomenon and not part of the pathologic response
The two‐minute neuro exam—cranial nerves
• Clench teeth checks CN V (trigeminal)‐‐symmetry
• Close eyes tightly—check for asymmetry, facial weakness
‐‐‐checks CN VII (facial nerve)
• Open eyes and follow movement with finger—eyes eyes track? ‐‐‐checking CNIII (oculomotor), IV (trochlear), VI (abducens)
• Light reflex/follow finger to nose (accommodation) –checks CNII (optic) and III (oculomotor)
• Optic fundus (CN II)
• KKK, pant like dog – checks CNIX (glossopharyngeal) and X (Vagus)
• Shrug shoulders‐‐checks XI (spinoaccessory)
• Stick tongue out—checks XII (hypoglossal) (XII)
The two‐minute neuro exam—mental status
• The Time and Change test
• Clock with hands
• 3 Quarters, 7 dimes, and 7 nickels
• What time is it?
• Please make change in the amount of one dollar
• Rules OUT dementia; 93% negative predictive value…
• What were those three things I asked you to remember?
• Adams HP, Corbette JJ, Dellyer WE. A quick neurologic exam. Patient Care 2000 (Feb. 15), 161‐74
• McGee S. Evidence‐Based Physical Assessment, Elsevier, 2012.
• The Achille’s reflex. According to legend, young Achilles was made almost impervious to harm when he was dipped in the magic river. However, since he was held by the heels, he remained vulnerable at that point, hence, the Achilles heel and tendon. The Achilles tendon reflex is vulnerable to disc herniations and other causes of S1 nerve root impingement or damage.
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Panic disorder as a cause of chest painQ: When you are nervous, how often do you think, “I am going to pass out”…
1) never, 2) rarely, 3) ½ the time 4) usually 5) always
Q: During the last 7 days, including today, how much have you been bothered by pains in the chest?
1) Not at all 2) little bit 3) moderately 4) quite a bit 5) extremely
Q: To what degree is your chest pain tiring or exhausting?
1) None 2) mild 3) moderate 4) severe
76% of patients w/ score < 4 will not have panic disorder; 71% of patients with a score ≥ 5 will have panic disorder
The many causes of headache—some notes on PQRST + AAA• Migraine—gender differences, menstrual migraines
• Tension
• Cluster (males; clusters; around eye; tearing; runny nose, ptosis)
• Brain tumor (or any other space‐occupying lesion, such as subdural hematoma)—early morning;
• Early morning headaches‐‐Sleep apnea, carbon monoxide poisoning, and space‐occupying lesions such as tumors, subdural hematomas), bruxism
• Hangover headache
• Hypertension
• Caffeine withdrawal (post surgery, cold turkey)
• Vision, TMJ, bruxism
One other way to assess the reliability of physical findings• The kappa (ĸ) statistic – assesses the reliability of intraobserver agreement—how often multiple physicians agree that a particular physical sign is present or absent
• A ĸ‐value of 0 indicates that observed agreement is the same as that expected by chance, but a ĸ –value of 1 indicates perfect agreement, so: 0 to 0.2 is slight agreement, 0.2 to 0.4 fair, 0.4 to 0.6 moderate, 0.6‐0.8 substantial, 0.8 to 1 is almost perfect!
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Example: jugular vein distention vs. the abdominojugular reflex for CHF
• Jugular vein distention—0.08 – 0.71
• Abdominojugular test – 0.92
• So, which is the most reliable test for CHF?
Differential Diagnosis of Jugular Vein Distention• Congestive heart failure
