Wednesday, December 21, 2011

~aku bukan parasit~ #002 CVS examination


nk share skit psl CVS examination, sekadar yg tahu, mgkin ad silap ataupun salah, tlglah betulkan ye.

mcm biasa, PPD sntiasa diamalkn, introduce urself.

next, exposure, position(45 degree/higher if pt is uncomfortable)

sume da ok --> g end of the bed: General inspection(Dr ckp student slalu lupa tang ni, so tgkla sume2 ea, any branula/drips/infusion/oxygen mask/sputum cup/inhaler). ringkasnya, apa2 barang yg ad kt sekeliling pt tuh~ (klu neuro, mgkin leh tgk tongkat/walking frame). N kalau da nmpk tu, pandai2la describe, (mgkin site/type of drip/infusion).

Dr pun ad mention ttg venti mask. cmne nk bezakan face mask VS venti mask? ans: presence of venturi valve(yg warna-warni tuh). Xperlu hafal colour coding utk venturi valve, sbb lain hospital, lain colour coding yg digunakan(Dr ckp) tp make sure check bpe conc oxygen yg digunakn...

Ok, next section> inspection of the hands

firstly, tgk ad clubbing x? causes of clubbing: IE, congenital cyanotic heart ds(transposition of great arteries, tetralogy of Fallot). n tgk jgk stigmata of IE(clubbing, Janeway lesion, Osler's nodes, distal emboli, splinter hemorrhage). splinter hemorrhage ni can have other causes jgk. Cthnya: trauma(most common)n vasculitis.

pastu jgn lupa pulse(radial pulse). Pulse kene describe tiga benda:rate(bpm), rhythm n volume, character(eg. collapsing pulse).

**collapsing pulse: mula2, tny pt ad x sakit kt bahu(sbb kta nk agkt tgn dia, klu sakit n dia xbg agkt, xyah k?). pastu guna tpk tgn anda: use ur palm and feel for the pulse. then release it until u can no longer feel the pulse and life the patient's arm. If u feel the pulse/bounding pulse then there is presence of collapsing pulse. Nape name dia collapsing pulse? sbb korg dpt rasa pulse yg kuat pastu tetba hilang... hmm, xpernah experience tp dgr org ckp n bc definition, mcm tu la...

then check for radio-radio delay n radio-femoral delay

-> face examination

look for signs of hypercholesterolemia(xanthelasma/corneal arcus). Tapi corneal arcus is common in elderly, so not necessarily that elderly pt has cholesterolemia if s/he has corneal arcus. But if u see corneal arcus in a young pt, then it is a sign of hypercholesterolemia. Check for anemia/jaundice.

Oral hygiene(might be source of IE)
central cyanosis(under the tongue)
high-arched palate(use a torch, make sure u see enough palate to identify a high-arched palate)

->neck examination

Then check for JVP(jugular venous pressure)- refers to IJV; how to locate IJV? hmm, u need to know the course of IJV; it runs from the TMJ(temporomandibular joint) and its inferior end passes in between the sternal and clavicular heads of SCM(sternocleidomastoid muscle). So basically, tgk TMJ n the region btwn the two heads of SCM, make a perpendicular line, n look somewhere there(last sentence ni teori sy sndiri yg diadaptasi drpd teaching dgn specialist, xde mention dlm mana2 textbook, so klu xnk caya pun xpe). btw, IJV lies deep to SCM, so SCM ni kira a good landmark for JVP. pastu, to identify JVP, u need to know its characteristic, (it is visible but not palpable, double pulsation[bc blik physio nape double pulsation k?], positive hepatojugular reflux, the pulse obliterated by touch, decreases with inspiration). dlm stiap sume ni, msti ad sebab dia kn? so, back to basics-physio

***in case there is raised JVP, must palpate for liver!(According to Dr N)

-> chest

inspection: chest deformities, scar (e.g, midline sternotomy: CABG or valvular replacement), pacemaker(look at both left n right sides)and precordium: visible pulsation?

palpation: start with apex beat(start from most lateral and inferior). locate(normal position-5th I.C space, mid-clavicular line) and describe its character (normal, tapping, heaving, thrusting, double-pulsation).

**normal is normal, tapping is only in mitral stenosis(only mention it if u r sure there is murmur there), heaving is when there is increased resistance(stenosed/restricted outlet or systemic HPT), thrusting(volume overload. eg., mitral regurg, tricuspid regurg, CCF), double-pulsation(don't know the reason of this. anyone knows?)

However, you might not be able to palpate the apex beat. So what can be the causes? Anything that can prevent the transmission of the pulsation to your hand(obesity, pneumothorax, pleural effusion, pericardial effusion). You might want to ask the pt to move to left lateral position if you can't feel the apex beat.

palpate the thrills(over the area of each valve: mitral, tricuspid, pulmonary, aortic)- use the tip of ur finger
and also look for parasternal heave(use the heel of ur palm)


start with bell(low-pitch) over the mitral area/apex to look for murmur radiating to the axilla. if nothing, then change to diaphragm, listen again and go to the next valve. usually the sequence is mitral-tricuspid-pulm-aortic. also, when u find a murmur, u need to perform the manoeuvre to accentuate the murmur and where it radiates to(i won't tell bout this coz im not yet sure myself). u also need to listen over carotid artery(both sides) for radiation of aortic murmur or perhaps carotid bruit(in case of carotid stenosis).

n ask the pt to sit up n auscultate the aortic area(right 2nd IC space)- a manoeuvre for aortic regurg(previously written as mitral regurg. sorry for the mistake). then, auscultate the base of the lung(bibasal creps) and check for sacral edema.

Last but not least, never forget pitting edema(and of course, always look at the patient's face!)

lupa lak nk ckp: Dr pesan, klu ad peripheral signs of IE, palpate for spleen!

n after u have finished ur examination, present everything in sequence. yg plg pnting: murmur(describe the site/radiation if any, type and grade), pt in failure or not, in sinus rhythm or not.

your finishing sentence: "this pt has the clinical evidence of ____________ (e.g, mitral stenosis, aortic stenosis, etc. )

in case u got exam question such as "palpate this pt's radial pulse", u still nd to do general inspection(at the end of the bed) n mention everything about the pulse~

All in all, Dr N ni mmg style~ jom kta sama2 doa dia dpt hidayah dr Allah...

**pt yg ad AVF(arteriovenous fistula- yg utk hemodialysis tuh) xdpt rasa radial pulse sbb da ad connection btwn artery n vein..

isu semasa: nk kuar study grup???

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