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(Dub) 6 : The Last Exam


Evaluating a patient who presents with cardiac symptoms is a complex and multi-step process. In addition to obtaining a thorough history, a detailed cardiac examination is of paramount importance. In the era where medical technologies advance rapidly, one may think that savvy medical diagnostics such as echocardiography or cardiac CT-scan can replace a thorough cardiac exam readily. But one must remember, a combination of a comprehensive history and detailed cardiac exam can diagnose almost 80% of cardiac disease. The decline of physical exam skills in the new generation of physicians is a well-documented phenomenon.[1] A good physical exam can save lives by rapid diagnosis and treatment as most of the diagnostic studies take time to result. Here we discuss the four pillars of the cardiac exam, i.e., history taking as well as inspection, palpation, and auscultation.




(Dub) 6 : The Last Exam



To perform a successful physical exam, one must understand the structural anatomy of the heart. The heart is a thoracic organ-confined between the lungs, above the diaphragm. It's divided into four chambers, two atria and two ventricles, respectively. The atria are separated by the interatrial septum, while the interventricular septum separates the ventricles.


The cardiac exam generally includes inspection, palpation, and auscultation. The examiner should be on the right side of the bed, and the head of the bed can be slightly elevated for patient comfort.


Auscultation of heart sounds is the cornerstone of any physical exam. It is usually with the assistance of a stethoscope. Most stethoscopes have two areas, the bell, and the diaphragm. The bell should be applied lightly to the skin and is useful in identifying low-pitched sounds such as gallops, murmurs of AV stenosis, and bruits. The diaphragm should be pressed tightly against the skin and helps identify high-pitched sounds such as valve closures, regurgitant murmurs, and systolic clicks.


The examiner should perform auscultation in four standard positions; supine, left lateral decubitus, upright, upright leaning forward. Generally, the examiner should start with the patient in the supine position and listen to all the cardiac areas in the aortic, pulmonic, tricuspid, and mitral regions in the locations previously described for S1 and S2 sounds and any systolic murmurs. While auscultating at the Left lower sternal border, one should determine if there is an S3 or S4 heart sound heard. S3 heart sound can be physiologic in children and athletes but can also be heard in patients with heart failure. S4 heart sound is produced from blood ejecting into a stiff ventricle and is also present in heart failure. The examiner should then turn the patient into the lateral decubitus position to listen for the low pitched diastolic murmur of mitral stenosis. The patient then turns upright, and all the areas are examined with the diaphragm of the stethoscope to listen for S1 and S2 sounds and any systolic and diastolic murmurs. The patient then should be leaned forward and asked to hold their breath; the examiner should then listen for the murmur of aortic regurgitation as well as any friction rubs. These sounds are extracardiac, usually originating in the pleura or the pericardium, and have a sound similar to scratching on sandpaper. These may result when there is irritation of these membranes as in pleuritis or pericarditis. Of note, the examiner should pay close attention to the influence of breathing on the nature and intensity of heart sounds. Most murmurs coming from the right side of the heart become accentuated with inspiration.


With auscultation of heart sounds, the examiner must be able to identify and describe murmurs. Murmurs can be either systolic or diastolic, so their timing relative to S1 and S2 is crucial. The timing of the heart sounds corresponding to the carotid pulse can help reliably identify S1 and S2. The sound that precedes the carotid pulse is S1, whereas the sound that follows it is S2. For this to work, only the carotid pulse should be used, not the radial, as there is a significant delay between the sound of S2 and the pulsation.


If a murmur is present, the following features require inspection; timing, location, radiation, duration, intensity, pitch, quality, relation to respiration, and maneuvers such as Valsalva or hand grip.[10] The timing of murmurs relative to systole and diastole is critical, i.e., a murmur beginning with S1, lasting through to S2, is likely a holosystolic or pansystolic murmur. A systolic ejection murmur begins with S1 but ends before S2. Does the murmur peak, or is it uniform throughout? The murmur of aortic stenosis classically is described as a crescendo decrescendo murmur; it has a peak in the middle.[10] Examiner must also identify in which area the murmur is bed heard and whether the murmur has radiation to other areas such as the axilla, neck, or back. The murmur should then be graded on a level from I to VI. The Levine murmur grading system is the gold standard of documenting intensity[11]


In an era of rapidly advancing medical diagnostic technology, it can be easy to overlook history and physical examination. Clinicians must be proficient in these skills to develop differentials and THEN order tests to confirm or refute differentials. Many diseases can be diagnosed solely based on good history taking and physical exam skills. The cardiac examination, in particular, is of vital significance when it comes to a thorough evaluation of the heart and differentiating between cardiac disease and diseases of other origins. Furthermore, the physical contact between the clinician and the patient during an encounter can also help create a psychological bond that provides reassurance and generates trust.


All healthcare workers should know how to perform a physical exam. The cardiac exam can quickly provide important information that can aid in the rapid diagnosis of many life-threatening diseases. In the inpatient setting, the cardiac exam should be a part of routine history and physical during admission and should be done daily. In the outpatient setting, the cardiac exam is still the most appropriate method to screen for cardiac disease and establish a diagnosis.


Abnormal uterine bleeding means that periods may be heavier or last longer than normal or not come at all. Bleeding between periods is also a sign of AUB. AUB isn't usually a major problem, but it can lead some girls to develop anemia (fewer red blood cells than normal).


Because AUB isn't usually a problem, doctors often don't do anything about it. But sometimes they take action if a medical condition is causing AUB. Doctors also might treat AUB if it is causing another problem. For example, doctors may worry that a girl could get document.write(def_anemia_T); anemiaif she is bleeding more than she should.


Anovulation is most likely to happen after a girl first starts getting her period. That's because the signals from the brain to the ovaries aren't fully developed yet. It can last for several years until a girl's periods become regular.


A doctor will want to rule out other health problems before deciding a girl has AUB. For example, doctors might find out that a girl with heavy periods has a bleeding disorder like von Willebrand disease.


Girls who have had sex and miss a period need to see a doctor. Missed periods could be a sign of pregnancy as well as a sign of AUB. If you have heavy bleeding or bleeding between periods, it could be an infection or other problem. For example, an ectopic pregnancy (when a pregnancy implants someplace other than the uterus) can cause bleeding, and can be life-threatening.


The most probable etiology of abnormal uterine bleeding relates to the patient's reproductive age, as does the likelihood of serious endometrial pathology. The specific diagnostic approach depends on whether the patient is premenopausal, perimenopausal or postmenopausal. In premenopausal women with normal findings on physical examination, the most likely diagnosis is dysfunctional uterine bleeding (DUB) secondary to anovulation, and the diagnostic investigation is targeted at identifying the etiology of anovulation. In perimenopausal patients, endometrial biopsy and other methods of detecting endometrial hyperplasia or carcinoma must be considered early in the investigation. Uterine pathology, particularly endometrial carcinoma, is common in postmenopausal women with abnormal uterine bleeding. Thus, in this age group, endometrial biopsy or transvaginal ultrasonography is included in the initial investigation. Premenopausal women with DUB may respond to oral contraceptives, cyclic medroxyprogesterone therapy or cyclic clomiphene. Perimenopausal women may also be treated with low-dose oral contraceptives or medroxyprogesterone. Erratic bleeding during hormone replacement therapy in postmenopausal women with no demonstrable pathology may respond to manipulation of the hormone regimen.


If abnormal uterine bleeding is not severe and does not require emergent intervention, evaluation begins with a careful medical history, including the usual menstrual pattern, the extent of recent bleeding, sexual activity, trauma and symptoms of infection or systemic disease. A complete physical examination, supplemented by laboratory testing, should uncover any signs of systemic disease.


The pelvic examination consists of careful inspection of the lower genital tract for lacerations, vulvar or vaginal pathology and cervical lesions or polyps. Bimanual uterine examination may reveal enlargement from uterine fibroids, adenomyosis or endometrial carcinoma.


An approach to the premenopausal woman with abnormal uterine bleeding is outlined in Figure 1. If the reproductive-age woman is not pregnant and has a normal physical examination, abnormal uterine bleeding is usually dysfunctional in nature and can be managed with hormonal therapy.


With continuous combined hormone replacement therapy, up to 40 percent of women have irregular bleeding in the first four to six months of therapy.19 Bleeding is more common when hormone therapy is started less than 12 months after menopause. Most sources recommend evaluation of abnormal bleeding if it lasts more than six to nine months after initiation of hormone replacement therapy. An approach less widely recommended is cessation of hormone therapy followed by a diagnostic evaluation if the bleeding does not stop within three weeks.19 041b061a72


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