History Taking & Physical ExaminationHistory Taking & Physical Examination. .

CHAN SOVANDY, M.D.CHAN SOVANDY, M.D.

International University, Phnom Penh International University, Phnom Penh

OutlineOutline• Anatomy and physiologyAnatomy and physiology

• Surface projections of the heart and great vessels Surface projections of the heart and great vessels • Cardiac chambers, valves, and circulationCardiac chambers, valves, and circulation• The heart soundsThe heart sounds• Heart murmursHeart murmurs• Relation of the auscultatory findings to the chest wallRelation of the auscultatory findings to the chest wall

• Techniques of ExaminationTechniques of Examination• The arterial pulseThe arterial pulse• Blood pressureBlood pressure• Jugular venous pressure and pulsesJugular venous pressure and pulses• The heartThe heart

• Special techniquesSpecial techniques• Pulsus alternansPulsus alternans• Pulsuss paradoxusPulsuss paradoxus

• SummarySummary

Surface projections of the Surface projections of the heart and great vessels- RV heart and great vessels- RV and PAand PA• RV cover most of RV cover most of

anterior cardiac anterior cardiac surfacesurface

• RV meets PA at left RV meets PA at left border of sternum border of sternum and at the 3and at the 3rdrd rib rib levellevel

Surface projections of the heart Surface projections of the heart and great vessels – LV , Aorta, RA and great vessels – LV , Aorta, RA and LAand LA• LV occupies just small portion LV occupies just small portion

of anterior cardiac surfaceof anterior cardiac surface• LV produces the “apical LV produces the “apical

impulse” – seen at the 5impulse” – seen at the 5thth interspace, 7 to 9 cm from the interspace, 7 to 9 cm from the midsternal linemidsternal line

• Aorta: right sternal border at Aorta: right sternal border at the 3the 3rdrd rib rib

• RA from R border of the heart, RA from R border of the heart, it is usually not identified on PEit is usually not identified on PE

• LA is mostly posterior and LA is mostly posterior and cannot be examined directlycannot be examined directly

Cardiac chambers, Valves, and Cardiac chambers, Valves, and CirculationCirculation

• AV valvesAV valves•TV and MVTV and MV

• Semilunar (SL) valves Semilunar (SL) valves •AoV and PVAoV and PV

• The vibration of those valves when The vibration of those valves when they are closed generate the normal they are closed generate the normal heart soundsheart sounds

Heart SoundsHeart Sounds• S1 when AV valves close at the beginning S1 when AV valves close at the beginning

of ventricular systolesof ventricular systoles• S2 when SL valves close at the beginning S2 when SL valves close at the beginning

of ventricular diastolesof ventricular diastoles• S3 is heard in children and young adults S3 is heard in children and young adults

during rapid ventricular fillingduring rapid ventricular filling• S4 is occasionally heard in normal adults S4 is occasionally heard in normal adults

during atrial contractionduring atrial contraction• Before LV filling begins, the MV valves Before LV filling begins, the MV valves

open. the opening of MV usually is silent, open. the opening of MV usually is silent, but it may be audible as an opening snap but it may be audible as an opening snap in mitral stenosisin mitral stenosis

Splitting of heart soundsSplitting of heart sounds

• Physiologically, the events occurring Physiologically, the events occurring on the right side of the heart are on the right side of the heart are slightly later than those on the leftslightly later than those on the left

•TV closes a bit later than the MV, this TV closes a bit later than the MV, this generates splitting of S1generates splitting of S1

•PV closes a bit later than AoV, this PV closes a bit later than AoV, this generates splitting of S2generates splitting of S2

• However, splitting of the heart However, splitting of the heart sounds are not normally heard.sounds are not normally heard.

Heart murmursHeart murmurs

• Heart murmurs differ from heart Heart murmurs differ from heart sounds by their longer durationsounds by their longer duration

• They are due to turbulent blood They are due to turbulent blood flow against the abnormal flow against the abnormal valves, too narrow( stenotic) or valves, too narrow( stenotic) or too wide (regurgitant)too wide (regurgitant)

Relation of the auscultatory Relation of the auscultatory finding to the chest wallfinding to the chest wall• Sounds and murmurs that originate Sounds and murmurs that originate

in:in:•The MV are usually heard best at The MV are usually heard best at

cardiac apexcardiac apex

•The TV are heart best at lower left The TV are heart best at lower left sternal border sternal border

•The PV are heard best at left sternal The PV are heard best at left sternal border at the 2border at the 2ndnd and 3 and 3rdrd interspace interspace

•The AoV are heard best at tight The AoV are heard best at tight sternal border at the 2sternal border at the 2ndnd and 3 and 3rdrd interspaceinterspace

Techniques of Examination- Techniques of Examination- The arterial pulsesThe arterial pulses• Arterial pulses detects:Arterial pulses detects:

•Rate of the heart Rate of the heart

•Rhythm of the heartRhythm of the heart

•Amplitude of the pulseAmplitude of the pulse

• Obstruction to blood flow( thrill on palpation Obstruction to blood flow( thrill on palpation and bruit on auscultatory)and bruit on auscultatory)

• Commonly used arterial pulses Commonly used arterial pulses •Radial pulseRadial pulse

•The carotid pulseThe carotid pulse

•The brachial pulseThe brachial pulse

Techniques of examination Techniques of examination Rate and rhythm of the heartRate and rhythm of the heart

• Rate the heartRate the heart•Use radial pulseUse radial pulse• If regular- count the number of pulse in 15 If regular- count the number of pulse in 15

secondsseconds×4×4• If irregular- count till 60 seconds and also do If irregular- count till 60 seconds and also do

the count by auscultating the heart because the count by auscultating the heart because beats that occur earlier than others may not beats that occur earlier than others may not be detected peripherallybe detected peripherally

• Rhythm of the heartRhythm of the heart•Also use radial pulseAlso use radial pulse•Better use auscultation when the rhythm is Better use auscultation when the rhythm is

irregularirregular

Techniques of examination Techniques of examination amplitude of the pulseamplitude of the pulse

• When radial pulse is rapid and weak (or When radial pulse is rapid and weak (or thread or small) it suggests hypotensionthread or small) it suggests hypotension

• When radial pulse is absent, it suggests When radial pulse is absent, it suggests that systolic BP is below 80 mm Hg.that systolic BP is below 80 mm Hg.

• We then proceed to palpate carotid pulse. We then proceed to palpate carotid pulse. if carotid pulse is present, it suggests if carotid pulse is present, it suggests systolic BP of at least 60 mm Hg. systolic BP of at least 60 mm Hg.

• The present of brachial pulse suggests The present of brachial pulse suggests systolic of at least 70 mm Hg. systolic of at least 70 mm Hg.

Techniques of examination Techniques of examination Thrill and Bruit Thrill and Bruit

• When palpating carotid pulse, note for When palpating carotid pulse, note for thrill, if thrill is present for bruit. The thrill, if thrill is present for bruit. The present of thrill or bruit mean the present of thrill or bruit mean the carotid artery carries an atheroma carotid artery carries an atheroma plaque.plaque.

• When palpating carotid pulse, avoid: When palpating carotid pulse, avoid: • Palpating over the carotid sinus which lies at Palpating over the carotid sinus which lies at

the top level of the thyroid cartilage.the top level of the thyroid cartilage.

• Palpating the 2 carotid arteries at the same Palpating the 2 carotid arteries at the same time.time.

Techniques of examination Techniques of examination Blood pressure Blood pressure

• Use proper cuffUse proper cuff• The width of the bladder should be 40% of the The width of the bladder should be 40% of the

circumference of the limb measured circumference of the limb measured

• The length of the bladder should be 80% of the The length of the bladder should be 80% of the circumference of the limb measured circumference of the limb measured

• Obese pt may need 15 cm wide cuff or 18 cm thigh Obese pt may need 15 cm wide cuff or 18 cm thigh cuff. cuff.

• The cuff that is too tight makes falsely The cuff that is too tight makes falsely high BP high BP

• Best to use sphymomanometer of mercury Best to use sphymomanometer of mercury type, yet aneroid one can be used with type, yet aneroid one can be used with regular calibration.regular calibration.

What is Blood Pressure?What is Blood Pressure?Blood pressure is a measure of the pressure of the blood Blood pressure is a measure of the pressure of the blood

Against the walls of the arteries ,it is dependant upon Against the walls of the arteries ,it is dependant upon the action of the heart ,the elasticity of the artery the action of the heart ,the elasticity of the artery walls and the volume and thickness of the blood .the walls and the volume and thickness of the blood .the blood pressure reading are a radio of the maximum or blood pressure reading are a radio of the maximum or systolic systolic

pressure (as the heart pushes the blood out to the pressure (as the heart pushes the blood out to the body ) written over the minimum or diastolic pressure body ) written over the minimum or diastolic pressure (as the heart begins to(as the heart begins to fill with blood )fill with blood )

Systolic pressureSystolic pressure

Diastolic pressureDiastolic pressure

Techniques of examination Blood Techniques of examination Blood pressure (cont’d)pressure (cont’d)

• No smoking or caffeine 30 min prior No smoking or caffeine 30 min prior

• Rest 5 min prior, relax in a quiet room Rest 5 min prior, relax in a quiet room

• Arm free of clothing and of AV fistula for hemodialysis Arm free of clothing and of AV fistula for hemodialysis

• Pt can be supine, sitting, or standing Pt can be supine, sitting, or standing

• Brachial artery at the level of the heart (junction of 4Brachial artery at the level of the heart (junction of 4thth interspace with interspace with the artery.the artery.

• Locate brachial artery Locate brachial artery

• Place lower border of BP cuff at 2 to 3 cm above antecubital creases with Place lower border of BP cuff at 2 to 3 cm above antecubital creases with its bladder on top of brachial artery.its bladder on top of brachial artery.

• Blow up the cuff until brachial pulse disappears, then about 30 mm Hg Blow up the cuff until brachial pulse disappears, then about 30 mm Hg high. high.

• Place the bell of stetoscope on brachial artery at the antecubetal Place the bell of stetoscope on brachial artery at the antecubetal creasescreases

• Deflate the cuff slowly 2 to 3 mmHg/second Deflate the cuff slowly 2 to 3 mmHg/second

• The first pulse heart is SBP and the last pulse heard is DBPThe first pulse heart is SBP and the last pulse heard is DBP

• Should take BP both arms, if high BP found => should measure legs BP Should take BP both arms, if high BP found => should measure legs BP and its pulse (to rule out coarctation of aorta, which gives BP in the legs and its pulse (to rule out coarctation of aorta, which gives BP in the legs than in the arms and pulses in the legs smaller than in those in the arms than in the arms and pulses in the legs smaller than in those in the arms ) )

What is Hypertension? What is Hypertension?

Hypertension is the result of persistent high arterial blood Hypertension is the result of persistent high arterial blood pressure which may cause damage to the vessels and pressure which may cause damage to the vessels and arteries of the heart ,brain ,kidneys ,and eyes. The entire arteries of the heart ,brain ,kidneys ,and eyes. The entire

circulatory system is affected since it become increasinglycirculatory system is affected since it become increasingly

more difficult for the blood to travel from the heart to the more difficult for the blood to travel from the heart to the

major organs. Multiple blood pressure readings are taken major organs. Multiple blood pressure readings are taken to to

establish an average and analyzed by a physician to establish an average and analyzed by a physician to determine hypertension determine hypertension

Techniques of examination Techniques of examination Jugular venous pulses and Jugular venous pulses and pressure pressure • Examination of the jugular veins pulsation helps Examination of the jugular veins pulsation helps

to estimateto estimate::• The jugular venous pressure (JVP), and The jugular venous pressure (JVP), and

• The pressure in the RA (or the central venous The pressure in the RA (or the central venous pressure: CVP)pressure: CVP)

• The JVP is an indicator of the CVP. The pressure in The JVP is an indicator of the CVP. The pressure in the internal jugular veins is a better indicator the internal jugular veins is a better indicator than the right one for the CVP, however, it is hard than the right one for the CVP, however, it is hard to examine as it lies deeps into the SC muscle to examine as it lies deeps into the SC muscle

• To look for pulsation of the internal JV, shinning To look for pulsation of the internal JV, shinning the light and look for the pulsation of the the light and look for the pulsation of the surrounding soft tissue near the external jugular surrounding soft tissue near the external jugular vein and along the SC muscle. Press over it to vein and along the SC muscle. Press over it to rule out carotid artery pulsation.rule out carotid artery pulsation.

Techniques of examination Techniques of examination Jugular venous pulses and Jugular venous pulses and pressure (cont’d)pressure (cont’d)• JVP does not depend on position. In JVP does not depend on position. In

position A, we cannot assess JVP as the position A, we cannot assess JVP as the jugular vein is full and lies under the chin, jugular vein is full and lies under the chin, so we need to change position to B or C.so we need to change position to B or C.

• Roughly, sternal angle is about 5 cm from Roughly, sternal angle is about 5 cm from the RA the RA

• Normally, JVP is about 3 to 4 cm above the Normally, JVP is about 3 to 4 cm above the sternal angle. Pressure above that means sternal angle. Pressure above that means high CVP (i.e. the RA has a high pressure, high CVP (i.e. the RA has a high pressure, which is seen in right sided heart failure)which is seen in right sided heart failure)

Indication for Placement of a Indication for Placement of a central Venous Catheter central Venous Catheter

--Measurement of central venous pressure Measurement of central venous pressure

-Rapid infusion of fluids -Rapid infusion of fluids

-Insertion of a transvenous pacemaker -Insertion of a transvenous pacemaker

-Parenteral alimentation -Parenteral alimentation

-Long term chemotherapy -Long term chemotherapy

-High risk for venous air embolism (place -High risk for venous air embolism (place catheter catheter

at junction of the superior cava and right at junction of the superior cava and right atrium)atrium)

CVP CVP BP BP Diagnosis Diagnosis FluidFluid low low/normal fluid lack

increase

high normal fluid overlord stop

high low cardiac failure restrict

p.s. CVP :normal :5-10cm of water

Techniques of examination The Techniques of examination The heart heart

• General approach General approach

• Inspection and palpation Inspection and palpation

• Percussion Percussion

• Auscultation Auscultation

Techniques of examination The Techniques of examination The heart: general approach heart: general approach • The examination stands on the right of the ptThe examination stands on the right of the pt

• Sequences of examination Sequences of examination – Supine with head elevated 30Supine with head elevated 300 0

• Inspect and palpate the precordium: the 2Inspect and palpate the precordium: the 2th th

interspace, the RV and the LV including the apical interspace, the RV and the LV including the apical impulse impulse

• listen at the tricuspid area with the bell listen at the tricuspid area with the bell

• Listen at all the auscultatory areas with the Listen at all the auscultatory areas with the diaphragm diaphragm

– Left lateral decubitus Left lateral decubitus • Listen at the apex with the bell of the stetoscope Listen at the apex with the bell of the stetoscope

– Sitting, leaning forward, after full exhalation Sitting, leaning forward, after full exhalation • Listen along the left sternal border and at the apex Listen along the left sternal border and at the apex

Techniques of examination The Techniques of examination The heart: inspection and palpation heart: inspection and palpation

• Use tangential light for inspection and use several Use tangential light for inspection and use several fingertips, then 1 fingertip for palpation fingertips, then 1 fingertip for palpation

• look at feel for location of the apical impulse (area of the look at feel for location of the apical impulse (area of the LV)LV)

• Apex of the heart normally is at the 5Apex of the heart normally is at the 5thth interspace interspace with the midclavicular line with the midclavicular line

• Apex that is displaced to the left means enlarged LV Apex that is displaced to the left means enlarged LV or enlarged heart or enlarged heart

• Look and feel for left sternal border impulses at the 3Look and feel for left sternal border impulses at the 3th th to to 55th th interspace of enlarge RV interspace of enlarge RV

• Look and feel at epigastric area for impulse of enlarged RV Look and feel at epigastric area for impulse of enlarged RV especially in obese or muscular pt. Index finger under the especially in obese or muscular pt. Index finger under the rib cage and up toward the left shoulder while the pt rib cage and up toward the left shoulder while the pt breaths in.breaths in.

• Feel for thrill in case there is murmur of intensity greater Feel for thrill in case there is murmur of intensity greater than 3/6. than 3/6.

Techniques of examination The Techniques of examination The heart: percussion heart: percussion

• Percussion helps to detect whether there Percussion helps to detect whether there is an enlarged heart when inspection and is an enlarged heart when inspection and palpation fail to detect due to:palpation fail to detect due to:

• Obesity Obesity

• Muscular chest Muscular chest

• Large pericardial effusion Large pericardial effusion • Markedly dilated failing hypokinetic apical Markedly dilated failing hypokinetic apical

impulseimpulse

• During percussion, starting well to the left During percussion, starting well to the left on the chest, note for dullness area of the on the chest, note for dullness area of the heart.heart.

Techniques of examination The Techniques of examination The heart: auscultation heart: auscultation • Location Location

• Learn to accustom yourself in doing heart Learn to accustom yourself in doing heart auscultation auscultation

• Start from right 2Start from right 2th th interspace close to the interspace close to the sternum and then left sternal border in each sternum and then left sternal border in each interspace from 2interspace from 2thth through the 5 through the 5th th , and , and finally at the apex.finally at the apex.

•Murmur that is heard at a location, though Murmur that is heard at a location, though often is a result of a valve abnormality at often is a result of a valve abnormality at that location, it may sometimes heard at that location, it may sometimes heard at other places (see the below picture)other places (see the below picture)

Techniques of examination The Techniques of examination The heart: auscultation (cont’d)heart: auscultation (cont’d)

• Use of stetoscope Use of stetoscope • Use diaphragm of your stetoscope for high-Use diaphragm of your stetoscope for high-

pitch sounds such as S1, S2, the murmur of pitch sounds such as S1, S2, the murmur of AR and MR, and pericardial friction rub. AR and MR, and pericardial friction rub. Press the diaphragm firmly and enough to Press the diaphragm firmly and enough to create and air seal with its full rim.create and air seal with its full rim.

• Use bell for low-pitch sounds such as S3, Use bell for low-pitch sounds such as S3, S4, and murmur of MS. Do not press the bell S4, and murmur of MS. Do not press the bell too hard, otherwise it will function as a too hard, otherwise it will function as a diaphragm and the low-pitch sounds that diaphragm and the low-pitch sounds that you want to listen for will disappear .you want to listen for will disappear .

Techniques of examination The Techniques of examination The heart: auscultation (cont’d)heart: auscultation (cont’d)• What to listen forWhat to listen for

– S1 S1 • Due to AV valves closure Due to AV valves closure

• Occurs at the same time as the carotid pulse Occurs at the same time as the carotid pulse

• Louder than S2 Louder than S2

• Usually loudest at the apex or the 4Usually loudest at the apex or the 4th th left interspace left interspace

– S2 S2 • Due to semilunar valves closure Due to semilunar valves closure

– Splitting of S1 and S2 Splitting of S1 and S2 • Splitting S1 ( MV close long before TV ): M1T1Splitting S1 ( MV close long before TV ): M1T1

• Splitting S2 ( AoV close long before PV ): A2P2 Splitting S2 ( AoV close long before PV ): A2P2 – A loud P2 suggest delayed PV closure in pulmonary A loud P2 suggest delayed PV closure in pulmonary

HTNHTN

Techniques of examination Techniques of examination The heart: auscultation The heart: auscultation (cont’d)(cont’d)• What to listen for What to listen for

– Pericardial friction rub Pericardial friction rub • Sound produced by the inflammed and rough Sound produced by the inflammed and rough

pericardiums rub against each other during early phase pericardiums rub against each other during early phase of pericarditis of pericarditis

– Extra sounds in systole Extra sounds in systole • Early systolic ejection sounds Early systolic ejection sounds

– Shortly after S1Shortly after S1– Coincident with the opening of AoV and PV Coincident with the opening of AoV and PV – Indicate AS if heard at aortic area, or pulmonary stenosis Indicate AS if heard at aortic area, or pulmonary stenosis

and pulmonary HTN if heard at pulmonic area.and pulmonary HTN if heard at pulmonic area.

• Systolic clicks Systolic clicks – Heard during mid-to late systole Heard during mid-to late systole – Originate from the abnormal motion of the MV such as in Originate from the abnormal motion of the MV such as in

MV prolapse MV prolapse

Techniques of examination The Techniques of examination The hear: auscultation (cont’d) hear: auscultation (cont’d) • What to listen for What to listen for

– Extra sounds in diastole Extra sounds in diastole • Opening snap Opening snap

– Due to the opening of MV that is thick and stenotic (i.e. Due to the opening of MV that is thick and stenotic (i.e. in mitral stenosis )in mitral stenosis )

– Best heard at lower left stermal border Best heard at lower left stermal border

• S3 (ventricular) gallop S3 (ventricular) gallop – Normal in children, it is heard during the rapid Normal in children, it is heard during the rapid

ventricular filling phase ventricular filling phase – In adult, it indicates too rapid and high ventricular In adult, it indicates too rapid and high ventricular

filling, an early sign of CHF filling, an early sign of CHF

• S4 (atrial) gallop S4 (atrial) gallop – Occur late in ventricular diastole (or at atrial Occur late in ventricular diastole (or at atrial

contraction) from an increased resistance to ventricular contraction) from an increased resistance to ventricular filling from ventricular stiffness as seen in HTN, AS, and filling from ventricular stiffness as seen in HTN, AS, and hypertrophic cardiomyopathy.hypertrophic cardiomyopathy.

Techniques of examination The Techniques of examination The heart: auscultation (cont’d)heart: auscultation (cont’d)• What to listen for What to listen for

– Heart murmursHeart murmurs• Sound produced by the turbulence of blood that flows Sound produced by the turbulence of blood that flows

through narrowed valves (stenosis), or flows through narrowed valves (stenosis), or flows backward (regurgitation0, or flows through abnormal backward (regurgitation0, or flows through abnormal passages (shunts as seen in VSD).passages (shunts as seen in VSD).

– When heart murmurs are heard, try to: When heart murmurs are heard, try to: • Time them Time them

– Systolic murmur, e.g. MR Systolic murmur, e.g. MR – Diastolic murmur, e.g. MSDiastolic murmur, e.g. MS– Holosystolic, e.g. MR, TR VSDHolosystolic, e.g. MR, TR VSD– Continuous, e.g. PDA Continuous, e.g. PDA

• Determine area best heard and its radiation, e.g. a Determine area best heard and its radiation, e.g. a systolic murmur that is best heard at aortic area and systolic murmur that is best heard at aortic area and also heard along the neck suggest AS also heard along the neck suggest AS

• Determine its intensity (1/6 to 6/6)Determine its intensity (1/6 to 6/6)

Determine the intensity of Determine the intensity of heart murmur – grade 1/6 to heart murmur – grade 1/6 to 6/6 6/6 • Grade 1/6 Grade 1/6

– Very faint, heard only after listener has tuned inVery faint, heard only after listener has tuned in

• Grade 2/6Grade 2/6– Quiet, but heard immediately after placing the stethoscope Quiet, but heard immediately after placing the stethoscope

• Grade 3/6Grade 3/6– Moderately loud Moderately loud

• Grade 4/6Grade 4/6– Loud murmur with a palpable thrill Loud murmur with a palpable thrill

• Grade 5/6 Grade 5/6 – Very loud, may be heard when the stethoscope is partly off Very loud, may be heard when the stethoscope is partly off

the chest the chest

• Grade 6/6 Grade 6/6 – May be heard when stethoscope entirely off the chest.May be heard when stethoscope entirely off the chest.

Special techniques Special techniques • Pulses alternans Pulses alternans

– One strong pulse alternates with one week pulse (pulse with One strong pulse alternates with one week pulse (pulse with alternating amplitudes)alternating amplitudes)

– Felt best on radial or femoral pulse Felt best on radial or femoral pulse – The presence of pulse alternans indicates left-sided heart The presence of pulse alternans indicates left-sided heart

failure failure

• Pulses paradoxus Pulses paradoxus – Normally, during expiration, blood pools back to the heart and Normally, during expiration, blood pools back to the heart and

make SBP 3 to 4 mm Hg greater than SBP during inspiration. make SBP 3 to 4 mm Hg greater than SBP during inspiration. – When the different is greater than 10 mm Hg, this is called When the different is greater than 10 mm Hg, this is called

pulse paradoxicus and is seen in cardiac tamponade or pulse paradoxicus and is seen in cardiac tamponade or constrictive pericarditis constrictive pericarditis

– TechniqueTechnique• Inflate BP cuff till no pulse and 30 mm Hg more Inflate BP cuff till no pulse and 30 mm Hg more

• Deflate BP cuff very slowly and note SBP at expiration (first heart Deflate BP cuff very slowly and note SBP at expiration (first heart sound heart at expiration) sound heart at expiration)

• Continue to deflate and note SBP when heart sound is heard both Continue to deflate and note SBP when heart sound is heard both at expiration and at inspiration at expiration and at inspiration

• Take the SBP expiration – SBP inspiration Take the SBP expiration – SBP inspiration

Summary Summary

• Explain the pt what you are going to Explain the pt what you are going to do do

• Position your pt, may be more than Position your pt, may be more than one one

• Start from top and move downStart from top and move down

• By order: inspection palpation, By order: inspection palpation, percussion, and auscultation percussion, and auscultation