R.e.p.o.r.t.s. .t.e.m.p.l.a.t.e.s (2).pptx

R.e.p.o.r.t.s. .t.e.m.p.l.a.t.e.s (2).pptx

1. Reports templates

2. Report on the pulse and vessels examination Central vessels inspection Neck vein distention – present/absent Kussmaul’s sign – present/absent Jugular veins pulsation- present/absent Carotid pulse (Corrigan’s sign )- present/absent

3. Report on the pulse and vessels examination 2. Arteries palpation Pulsation on Radial aa Brachial aa Axillar aa Carotids Temporal aa posterior tibial aa dorsalis pedis aa Poplitea aa Femoral aa Is Symmetrical (S=D)

4. 1. Pulsation on aa . dorsalis pedis is asymmetrical (S<D) or Pulse is absent/ diminished on a. dorsalis pedis sin. But preserved on a.dorsalis pedis dex . 2. Pulsation on other arteries (…..) is symmetrical (S=D)

5. Report on the pulse and vessels examination 3. Pulse properties on radial artery. symmetry, pulse rate, rhythm, volume (filling), tension, shape, structure of the artery wall out of pulse wave, size On radial aa. PS is symmetrical, pulse rate is 84 per min, pulse is regular, with normal filling and tense, shape is not changed, artery wall out of pulse wave is elastic and not painful (is not palpated), size is large (ps magnus). 4. Conclusion:

6. For the report: Inspection of the heart 1. “Cardiac humpback” – present/absent 2. Visible apex beat ( ( left ventricle ) - present/absent (its localization if present) 3. Pulsations near the sternum: II right ics (ascending aorta) - present/absent II lest ics ( truncus pulmonalis ) - present/absent 4. Visible pulsation in III-IV ics , left to the sternum – cardiac beat ( right ventricle ) - present/absent 5. Visible pulsation in e pigastric region – epigastric pulsation ( right ventricle ) - present/absent if any of signs is present – make a conclusion

7. For the report: Palpation of the heart 1. Apex beat is not palpated incl. on the left-side Apex beat is palpated on the left side, 2 cm in width (->conclusion); 4 cm in width ( ->conclusion) Apex beat is palpated in ( localisation ) V ics 2 cm medially from l.mediaclavicularis sin, of medium strength and hight , 2 cm in width AB is palpated in VI ics on l.axillaris ant., low ( hight ) and weak ( strenght ) 4 cm in width or diffuse and weak AD is palpated in ( localisation ) V ics , negative AD is palpated V ics 1 cm laterally from l.mediaclavicularis sin, vigorous and high (heaving AB) 2. Cardiac beat – absent/present 3. Epigastric pulsation – absent/present 4. Retrosternal pulsation – absent/present 5. Pulsation in 2 nd ics left absent/present Pulsation in 2 nd ics right absent/present if any of signs is present – make a conclusion

8. For the report: heart percussion The boarders of the relative cardiac dullness. Conclusion about the shape of relative cardiac dullness. Absolute cardiac dullness boarders. The upper – low border of the 4 th rib The right – on l.sternalis sin/ 1 cm medially from l.sternalis sin The left – on l. parasternalis sin/ 1 cm laterally from l.parasternalis sin. Conclusion about the shape of absolute cardiac dullness . General conclusion on the results of heart inspection, palpation and percussion. Right Left Upper   on the sternal line  2 cm medially from left midclavicular line 3d rib

9. Examination of the patient 1) Describe both sounds general intensity . For example: The sounds of the heart are … (loud, soft, very soft) 2) Identify S 1. Describe its intensity at the apex (not changed, soft, very loud), listen for S 1 splitting (split, wide split), point localization of the S 1 splitting. For example: The S 1 is …(not changed, loud, soft, very soft), not splitted or splitted on the apex. 3) Identify S 2 . Describe S 2 at the basis of the heart (accent (weakening) of S 2 on the aorta or pulmonary artery). Listen for S 2 splitting (split, wide split), point localization of the S 2 splitting. For example: accent (weakening) of S 2 on the aorta (pulmonary artery), splitted on the pulmonary artery and on the Botkin-Erb point. 4) Listen for extra heart sounds (S 3 , S 4, OS, clicks, murmurs or rubs), if any present, point it localization, and used maneuvers for best listening. 5) Listen for murmurs or rub . For murmurs describe relationship to the systole or diastole, location of the maximum intensity, intensity, duration, timbre, configuration, zones of radiation. For rubs – type of the rub and localization . 6) Give the conclusion about the condition of the myocardium, valves, main vessels

10. Report on lung auscultation Type of breath sound over the lungs vesicular , bronchovesicular, harsh Local change of breath sounds – absent / if present their type and localization Diminishing of breath sounds – absent / if present - diffuse, local and its localization Adventitious lung sounds absent / if present – type (crackles (fine, coarse), wheezes, rhonchi, pleural friction rub) and their localization and degree of intensity Conclusion