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 • 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 herebecause 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 • Don’t forget to do anterior and posterior for everything!!

9. Auscultation- • 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

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 • Don’t 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 Test…nuclear?? 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. 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.

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- • 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