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Advanced Physical Diagnosis Online Companion

The Cardiopulmonary Physical Exam

Rene Theophile Hyacinthe Laennec (1781-1826) with stethoscope
(painting date unknown)

The cardiopulmonary exam is widely regarded as the centerpiece of the comprehensive physical exam. Only through practice and repetition can learners hone their skills in this area to become excellent diagnosticians, however, like other portions of the physical exam, the cardiopulmonary exam can be divided into multiple sections to facilitate ease of learning.

One method we propose for dividing this important organ system is to begin by observing the patient’s appearance (age, body position, facial appearance, chest/abdomen respiration ratio, etc.), followed by attention to vital signs (heart rate, heart rhythm, blood pressure, respiratory rate, pulse oximetry, etc.), inspection of the great veins (jugular venous height, waveform, and respiratory variation), inspection of the great arteries (proximal and distal pulses), palpation of the cardiac apical pulse (size/diameter, location, intensity, etc.) and chest expansion, and finishing with auscultation of important anatomical areas (heart valves, major arteries, lung fields, etc.).

Learners may adapt this approach to their own style of physical examination, however, attention should be made not to skip any of the critical elements listed above.

We have included journal articles organized by individual physical exam skill and cardiopulmonary pathophysiology, as well as instructional videos for refining the cardiopulmonary exam.  

General Cardiopulmonary Exam Skills

OVERVIEW

Click to Access the Following PDFs:

1:Cardiac physical diagnosis in the digital age: an important but increasingly neglected skill (from stethoscopes to microchips)

2: Initial assessment and treatment with the airway, breathing, circulation, diability, exposure (ABCDE) approach

3: The examination of the heart: the importance of initial screening

4: Why does the heart beat? The discovery of the electrical system of the heart

5: A survey of health care practitioners' knowledge of the QT interval

6: Long-term outcome associated with early repolarization on electrocardiography

 

AUSCULTATION

Click to Access the Following PDFs:

1: Auscultation of the heart: examination of the heart, part 4

2: Editorial: On the genesis of heart sounds: contributions made by echocardiographic studies

3: Spread of heart sounds over chest wall

4: Current concepts in cardiology: Practical cardiac hemodynamics

5: Tricuspid component of first heart sound

6: Mechanism of normal splitting of the second heart sound

 

INSPECTION

Click to Access the Following PDFs:

1: Jugular venous pulse: an appraisal

2: How far is the sternal angle from the mid-right atrium?

 

PALPATION

Click to Access the Following PDFs:

1: The cardiac impulse and the motion of the heart

2: The cardiac apex impulse: clinical and angiographic correlations

3: Relationship between quantitiated precordial movement and left ventricular function

4: The left parasternal impulse

5: The clinical significance of systolic retraction of the apical impulse

Cardiopulmonary Exam Skills by Pathophysiology

ABNORMAL HEART SOUNDS

Click to Access the Following PDFs:

1: Auscultatory perception of the fourth heart sound: effects of intervals from fourth to first sound (S4-S1) and aging

2: Fourth heart sound as a normal finding in older persons

3: Paradoxical splitting of the second heart sound

 

 

 MURMURS

Click to Access the Following PDFs:

1: Etiology and diagnosis of systolic murmurs in adults

2: Echocardiography in the evaluation of systolic murmurs of unknown cause

3: First heart sound and ejection sounds: echocardiographic and phonocardiographic correlation with valvular events

4: Initial evaluation of heart murmurs: are laboratory tests necessary?

5: Venous hum in cardiac auscultation

6: Watson's water hammer pulse

 

 

CORONARY ARTERY DISEASE

Click to Access the Following PDF:

1: Bedside diagnosis of coronary artery disease: a systematic review

 

 

PERIPHERAL VASCULAR DISEASE

Click to Access the Following PDF:

1: Does the clinical examination predict lower extremity peripheral arterial disease?

 

 

HEART FAILURE

Click to Access the Following PDFs:

1: The Valsalva maneuver: a bedside "biomarker" for heart failure

2: Alterations in left ventricular volumes induced by Valsalva manoeuvre

3: Prognostic importance of physical examination for heart failure in non-ST-elevation acute coronary syndromes

4: Third heart sound and elevated jugular venous pressure as markers of the subsequent development of heart failure in patients with asymptomatic left ventricular dysfunction

 

 

PULMONARY HYPERTENSION

Click to Access the Following PDF:

1: Something subtle about death: isolated systolic pulmonary pressure

 

 

PERICARDITIS

Click to Access the Following PDF:

1: Pericardial rub: prospective, multiple observer investigation of pericardial friction in 100 patients

 

 

CARDIAC TAMPONADE/PERICARDIAL EFFUSION

Click to Access the Following PDFs:

1: Pulsus paradoxus in cardiac tamponade: a pathophysiologic continuum

2: Does this patient with a pericardial effusion have cardiac tamponade?

3: Misconceptions and facts about pericardial effusion and tamponade

 

 

ATRIAL FIBRILLATION

Click to Access the Following PDF:

1: "Presystolic" augmentation of diastolic heart sounds in atrial fibrillation

 

 

HYPOVOLEMIA

Click to Access the Following PDFs:

1: Is this patient hypovolemic?

2: Is this child dehydrated?

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