Cardiorespiratory

BY THE END OF THIS SESSION ENSURE THAT YOU:

è Understand the need for a professional physical examination

è Develop a sensitive attitude to collaborative working with patients

è Can accurately measure radial pulse rate and rhythm

è Can accurately measure blood pressure using a sphygnomanometer

A Starting the Examination

It is generally considered acceptable for There are accepted (and expected) doctors (and therefore medical students) to methods for examining patients used by touch patients. Nevertheless, all patients feel medics worldwide. Individual practitioners apprehensive when approached by a refine these methods for themselves as you stranger (even one in a white coat) who is will, with practice. Until you qualify (ie until about to inspect, percuss, palpate and you have convinced an examiner in Finals auscultate their body. Remember that for that you are able to examine patients using cultural, age and/or gender reasons this may the expected/traditional routine) it is best to be particularly so. It is essential to remain avoid deviating from the accepted methods! sensitive to your patients’ needs at all times. Q2 Suggest 3 reasons why there is a unifying Q1 Suggest 3 things you could do during your contact method of examining patients: with patients to promote their comfort/ease during the examination: 1

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3 Checklist for the examination

• Introduce yourself • Explain what you will be doing • Obtain verbal consent • Maintain patient dignity and privacy • Ensure adequate exposure • Ensure adequate lighting • Ensure you have the equipment you need (eg stethoscope, sphyg) • Position patient correctly (for CVS: sitting back on couch at 45 degrees) • Ensure patient is comfortable at all times B Inspection

These are your "first impressions" of the patient. Always begin any examination by standing back, to the right hand side of the patient. From this position very important (some say the most important) information can be gathered about your patient’s health.

Inspect your patient and as you do so, consider:

l does he look well or unwell l is he in pain l is he breathless l is he well­nourished l is he pale or flushed l are there any obvious abnormalities

Q3 Suggest 3 other points you might look for ‘from the end of the bed’:

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C Taking the Pulse

Method l Take the patient’s right hand. l Find the radial pulse with the fingers of your left hand (at wrist on palm side just above the ball of the thumb). l Compress the vessel gently against the bone beneath it (head of the radius).

⇒ You will now feel the pulsations of the radial artery.

Q4 If you find a visible pulsation under the skin how can you tell if it is from an artery or a vein?

Measuring the rate

The pulse rate is expressed in beats per minute (bpm). l Using the second hand of your watch (now’s the time to buy one!) allow 15 seconds to pass l In that time count the number of pulsations you feel l Multiply that number by 4 to express the rate in bpm

Normal pulse rates vary between 60 and 100 bpm. If the rate is less than 60 the pulse is described as bradycardic. If it is above 100 the pulse is tachycardic. Q5 What may cause a tachycardia?

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Measuring the rhythmn l Whilst taking the pulse consider: are the beats occurring in a regular rhythm or are they irregular?

Q6: Name a clinical condition in which the pulse is found to be irregular.

D Taking the Blood Pressure

The blood pressure is a very significant measurement: almost every patient will have their blood pressure taken at some point.

The sphygmomanometer allows estimation of this systemic blood pressure.

Method: l Ensure patient sitting comfortably l Remove all clothing from the non­dominant arm l Wind the cuff round that upper arm neatly and tightly nb: ensure the centre of the completely deflated rubber bag within the cuff is placed over the line of the brachial artery, the lower edge being kept 2­3 cm above the antecubital fossa nb2: ensure that if the girth of the upper arm is large choose a larger cuff to avoid innaccuracies in measurement. l Ensure correct position of the arm: l antecubital fossa in line with position of heart l arm slightly flexed l arm well supported (eg on table) l Position the manometer so that you can see the column of mercury and ensure it is at zero l Screw down the escape valve on the rubber bulb l Palpate the radial artery as before l Pump up the cuff using the bulb until the radial artery is no longer palpable. l Observe and remember the pressure reading on the manometer l Let down the pressure by rapidly unscrewing the valve l Now feel for the pulsations of the brachial artery on the medial side of the antecubital fossa l Place the diaphragm of the stethoscope over the point of maximum pulsation: you will hear nothing as the blood is moving smoothly through the vessel (laminar flow). Sounds are only associated with blood flow when this is turbulent. l Inflate the cuff again to a pressure reading 20mmHg above that previously needed to obliterate the radial pulse. The brachial artery is now totally occluded; no blood is flowing through it. l Apply the stethoscope again l Carefully and slowly let the pressure out of the cuff as before (no faster than 5mmHg per second) l Listen for the appearance of audible sounds.This is the 1 st Korotkoff sound: The pressure at which they appear is the systolic pressure. The brachial artery has just opened slightly, enough for blood to begin moving through it. l Continue letting the pressure out slowly. l Listen for the disappearance of sounds. This is the 5 th Korotkoff sound. (before they disappear they may muffle): The pressure at which they disappear is the diastolic pressure. The brachial artery is now fully open and blood flow is again laminar. l Record the blood pressure as the systolic value over the diastolic value in mmHg (eg 132/84mmHg) to the nearest 2mmHg l If you can’t hear the sounds clearly and want to try again let the cuff down completely between attempts. l Remove the cuff and leave the patient comfortable

Hypertension, or raised blood pressure is defined by the WHO as either a systolic reading greater than 160 or a diastolic reading greater than 90mmHg.

Q7: Assume your subject is completely healthy. Why might you have found his/her blood pressure to be raised?

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Q8: In what circumstances might the blood pressure be abnormally low?

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3 Return to the objectives for this session and ensure that you can:

è Understand the need for a professional physical examination ü

è Develop a sensitive attitude to collaborative working with patients ü

è Can accurately measure radial pulse rate and rhythm ü

è Can accurately measure blood pressure using a sphygnomanometer ü

Q9 The 3 most important things I have learnt from this session are

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3 Cardiorespiratory

BY THE END OF THIS SESSION ENSURE THAT YOU:

è Can localise the apex beat of the heart

è Can identify the mitral, tricuspid, pulmonary and aortic areas on the chest wall

è Can time the cardiac cycle during auscultation

è Can identify the first and second heart sounds by auscultation

è Can localise the internal jugular vein and measure its height

*Remember the principles of examining patients from Session 1*

A Apex Beat

Study the picture below which shows the position of the normal heart in the chest.

l Now lay the flat of your hand and outstretched fingers on the left of the sternum and locate the apex beat.

The apex beat is the furthest outward and downward point at which the cardiac pulsation is easily palpable. The normal apex beat (with the patient lying at 45 degrees) is in the 5th intercostal space in the midclavicular line. l Ensure you can locate this position by counting down the ribs Q1 Put a cross on the above diagram on the position at which the apex beat is most likely to be found.

Q2 Suggest three reasons why the apex beat may be hard to find/palpate.

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Q3 Suggest 1 reason why the apex may be displaced and palpable in the axilla

B Auscultation

Remind yourself of the four chambers and four valves in the heart and of how blood flows through them. Q4 Picture a blood cell in the superior vena cava returning from the body to the heart. Arrange the following list in the correct order to describe the structures it passes through next:

1 Mitral Valve 4 Lungs 7 Aortic valve

2 Left Ventricle 5 Pulmonary Valve 8 Right Atrium

3 Left Atrium 6 Right Ventricle 9 Tricuspid Valve

The diagram below shows the 4 positions to which the stethoscope is applied for auscultation of the heart.

M Mitral Area Apex

T Tricuspid Area Lower L sternal border (5th ICS)

P Pulmonary Area Upper L sternal border (2nd ICS)

A Aortic area Upper R sternal border (2nd ICS) nb ICS=InterCostal Space

Important: The positions describe where each valve may be heard best (with least interference) NOT the anatomical position of the valve itself! Further: a sound heard loudly in an area does not always come from that valve! Stethoscope

Q5 As the above diagram shows, the stethoscope has a diaphragm and a bell

Is the diaphragm better for listening to high or low pitched sounds?

Is the bell better for listening to high or low pitched sounds?

.l Angle the earpieces forward to match the direction of your external ear canal. l Place the diaphragm on the chest at each auscultatory area in turn (M, T, P then A). l Ensure that you can hear the heart sounds "lub­dub" each time

First Heart Sound: S1 "lub"

This is caused by the closure of the mitral and tricuspid valves just before ventricular systole (when contraction of the ventricles expels blood out of the heart)

Second Heart Sound: S2 "dub"

This is caused by closure of the aortic and pulmonary valves at the end of systole as the ventricles begin to relax (diastole).

The diagram below demonstrates this timing using standard shorthand notation derived from phonocardiography. C Timing the Cardiac Cycle

Systole corresponds to a pulse of blood in the carotid. S1 occurs just before and S2 just after systole. l To identify accurately which heart sound is which repeat your auscultation and as you do so place your thumb over the carotid artery in the neck. l Listen in all four areas and time the cardiac cycle as described.

D Splitting of S2

In young people the second heart sound may be split: "lub­da­dub" during inspiration and come together as one "lub­dub" in expiration.

l Listen to your patients/subjects heart in expiration and again in deep inspiration.

Can you identify the 2 components of S2?

Q6 In inspiration, more blood is returned to the right side of the heart than in expiration. As mentioned before S2 is a sound made by closure of the aortic and pulmonary valves.

Closure of which of these two valves is delayed, therefore in inspiration causing splitting of S2? E The Jugular Venous Pressure

The internal jugular vein (IJV) lies in the neck.

The measurement of the height of its pulse is an invaluable universal tool in the CVS examination.

It is also difficult to perform accurately without adequate preparation and practice!

The IJV is in direct communication with the Right Atrium (RA): there are no intervening valves between these two structures.

If the pressure in the RA is raised the Jugular Venous Pressure (JVP) will also be raised. The IJV will be distended and the height of its pulsation in the neck elevated. The JVP is therefore a manometer of RA pressure.

This enables pressure changes in the heart to be predicted by simple clinical observation.

Q7 Will the JVP be higher if a person is standing or lying flat?

Q8 Name three clinical causes of a raised JVP.

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Normal RA pressure is equivalent to that exerted by a column of blood 10­12cm tall. However, the RA is obviously not palpable or visible. Therefore the JVP is measured from the manubrosternal angle (MSA): the MSA is a constant height above the mid­RA.

The normal JVP with the patient at 45 degrees is less than 4cm above the MSA, the pulsation just visible above the clavicle. Measuring the JVP l Lie patient at 45 degrees with head turned slightly away from you. l Identify sternocleidomastoid muscle in the neck

(if unsure ask patient to try to turn their head back towards you against resistance: the muscle will contract in the neck) l Now rest head on pillow to relax this muscle l Identify the anatomical landmarks of the path of the IJV: it usually is seen emerging above the clavicle lateral to the sternocleidomastoid muscle. l If you can see the JVP (as mentioned, normally pulsation visible just above the clavicle) measure its height from the MSA as illustrated below.

If you cannot see the IJV repeat the procedure using the EXTERNAL jugular vein (EJV) instead which is often easier to find in practice. This vein is less reliable as a manometer of RA pressure because its communication with the SVC may be obstructed as it passes through the neck

To ensure the EJV is patent and therefore reliable as a manometer l Occlude EJV high up in the neck with your forefinger l With your other hand stroke the blood down into the thorax l When you release this stroking finger, if the column of blood in the EJV fills from below, the vein is patent and safe to use as a measure of the JVP Important: Arterial pulsation may also be visible in the neck and must be distinguished from venous pulsation. The common carotid artery runs with, though slightly lateral to the IJV in the carotid sheath of the neck.

Palpating the carotid artery

To distinguish JVP from carotid pulsation

1 Inspiration causes venous pulsation to fall

2 The venous pulsation is not palpable (see photograph above)

3 The height of the JVP is affected by position of the patient

4 The venous pulse normally has 2 peaks per impulse ie its waveform is bifid as the diagram below demonstrates. Cardiorespiratory

BY THE END OF THIS SESSION ENSURE THAT YOU:

è Know the anatomical landmarks of the lungs and mediastinum

è Can accurately measure Respiratory Rate

è Can assess Chest Expansion

è Can locate the position of the trachea

è Have practised percussion of the chest and can recognise normal

Resonance

è Can auscultate the chest and recognise normal Breath Sounds

A Anatomical Landmarks

The lobes of the lung

The Right Lung has upper, middle and lower lobes

The Left Lung has only upper and lower lobes (the lingula which corresponds to the R middle lobe is part of the L upper lobe)

Lung disease can affect one or more lobes of the lung in isolation from the rest. In order to examine the respiratory system accurately it is essential therefore to know the anatomical position of each lobe. Q1 On the following diagram label the positions on the chest with the lobes underlying them (use the previous diagram to help you)

Important

1 A substantial amount of lung is against the lateral chest wall.

Therefore ensure you include the axillae in your respiratory system examination.

2 Most lung volume is posterior in the chest.

Therefore the majority of signs in lung disease are picked up examining the back of the chest. l Now locate the lobes of the lung on your patient/subject from the front and back of their chest wall using the diagrams you have annotated above.

B Respiratory rate l Watch your subject breathing in and out: the chest wall rises and falls with each breath. l Allow 15 seconds to pass (still not bought a watch?!) and count the number of breaths your subject makes. l Record this as Breaths per Minute.

At rest the normal respiratory rate is 14­20 Breaths per Minute Q2 Suggest 3 causes of a raised respiratory rate:

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Q3 At rest is more time spent breathing in or breathing out?

C Chest Expansion

Lung volumes/capacity are assessed using spirometry, a technique you will learn on this course in a Practical Session.

However, a crude assessment of how much air can be shifted by a person’s lungs may be made at the bedside. In addition this test determines if both sides of the chest move symmetrically.

Method

1 (for keen beans) l Place a tape measure around the chest at the level of the nipples. l Ask patient to breathe in as deeply as possible. l In fit young men the chest may expand 5­8cm

2 (for the rest of us) l Place your hands in the subject’s axillae. l Bring your thumbs together over their sternum. l Keep your fingers/palm (but not thumbs) in firm contact with the chest wall. l Ask the subject to breathe in as deeply as possible. Watch as your thumbs move apart.

Q4 Suggest 1 reason why chest expansion may be reduced. D Position of the Trachea

You will recall from the last session how the position of the apex beat was determined by palpation. Further indication of the position of the mediastinum comes by feeling for the trachea in the neck:

The trachea moves with the upper part of the mediastinum, the apex beat with the lower part.

Method l Position you patient as before with their head well supported on the pillow, looking straight ahead this time. l Gently place two fingers either side of the trachea as it enters the chest and judge whether the distances between it and the sternocleidomastoid tendons are equal on both sides.

Important: The Police use this manoeuvre as a means of self­defence against an assailant. Your patient is not your assailant so remember to proceed very gently!

E Percussion

The purpose of percussion is to detect the resonance or hollowness of the chest.

Practice percussion before the session on different surfaces: solid and hollow.

Compare

1 The sound generated

2 The vibration felt by you hand flat on the surface

Method (for right­handed physicians...) l Press L hand flat on surface with fingers separated l Strike distal interphalangeal joint of L middle finger (or thereabouts) with the end of the R middle finger. l Ensure R hand movement achieved by wrist flexion not finger flexion l Ensure striking finger hits L hand at right angles to it l Ensure striking finger bounces off L hand immediately to avoid dampening the sound. Note: Every eminent chest physician was once a keen medical student who practised percussion on everyone and everything who would stay still.

Percussing the chest l Press L hand on chest parallel to the ribs with the L middle finger in an intercostal space. l Percuss the front of the chest first: l Compare L and R sides in turn as you move down from clavicle to lower border of the ribs. l You should percuss at 2 or 3 levels on front of chest l Percuss each axilla next l Now ask the patient to lean forward and percuss the back l Compare L and R sides at each level as before l Percuss at 3 or 4 levels as you move down from top of scapulae to bottom of rib cage. l Consider as you percuss which lobe of the lung you are examining

When you were percussing the front of the chest, towards the bottom of the R rib cage, the percussion note becomes dull (go back and check if necessary)

Q5 What solid organ is lying under the rib cage at this point to cause the dull percussion note?

F Auscultation l Using the diaphragm of the stethoscope, listen to the chest in each of the positions you have just percussed (front, axilla then back comparing L to R at each level as you move from top down) l Ask your patient to breathe in and out through the mouth. l At each point, listen to inspiration and to expiration Breath sounds

The sound you are hearing is GENERATED in the large airways (trachea and main bronchi). Sounds are ATTENUATED by the distal lung structures through which they pass. It is a common misconception that as you auscultate you are listening to air entry to the lobe of the lung in the area directly beneath your stethoscope.

The breath sound heard over normal lungs is termed Vesicular: it has a rustling quality and is heard on inspiration and the first part of expiration (see diagram below):

Return to the objectives for this session and ensure that you:

è Know the anatomical landmarks of the lungs and mediastinum ü

è Can accurately measure Respiratory Rate ü

è Can assess Chest Expansion ü

è Can locate the position of the trachea ü

è Have practised percussion of the chest and can recognise normal Resonance ü

è Can auscultate the chest and recognise normal Breath Sounds ü

Q6 The 3 most important things I have learnt from this session are

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