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CARDIOVASCULARSAMPLEWRITEUP

Belowisasamplewriteupofapatientwithoutanysignificantphysicalexamfindings.
Pleasepretendasthoughyousawoneofdiseasecasesfromthehandoutgiveninclass&
replacethephysicalexamfindingsbelowwiththoselistedinthecase.Ifnoinformation
wasgiveninthecase,assumeanormalfinding(i.e.suchasafindingfromyourlab
partner).(4pt)

Date:Physicalexamon2January2007,10:15am
ID:Name,age,dateofbirth,profession
CC:chiefcomplaintandduration

Vitalsigns
Temp:98F
Pulse:60,regularrateandrhythm
Resp:12
BP:125/75(sitting,rightarm)
Pain:0/10
2ndBP:148/84(seated,rightarm)
Height:53(bypt.report)
Weight:132#(bypt.report)
BMI:pleasecalculate(kg/m2)

Cardiac
Inspection:Chestissymmetric,noscars.Nocardiacheavesorlifts.Symmetrical
expansionwithrespiration,nootherwallmotions.
Palpation:Nothrillsappreciated.Pointofmaximalimpulse(PMI)(apical
impulse)notedatmidclavicularline,infifthintercostalspace.
Auscultation:NormalS1andS2,withregularrateandrhythm.S2>S1atthe
base,S1>S2atapex.Nosplittingoftheheartsoundsheard.Nomurmur.No
S3orS4,nofrictionrub.
Maneuvers:Nomurmurisheardwhilesquattingoruponreleaseofvalsalva,standingor
duringvalsalvastrain.

Drawtimingdiagram:
S1

S2

S1

S2

Neck:
Inspection:Nojugularvenousdistentionorpulsations.
Auscultation:Nocarotidbruits,ortransmittedmurmur.Carotidpulses2/4
bilaterally.

Peripheralvascular:
Extremities
Inspection:Norashes,swelling,colorchange,orcyanosisinarmsorlegs.Nosigns
ofvenousstasisorarterialinsufficiencyinlegs,withnormalhairdistribution,andno
pigmentationaroundankles.Nospiderveinsonlegsandthighsbilaterally.No
clubbinginfingernails.Capillaryrefillisbrink(<1sec).
Palpation:Handswarmandpink.Feetareabitcooltothetouchandpale,butequal
bilaterally.Nopittingornonpittingedemainfeet.
PalpationofPulses:
Carotid:2/4bilaterally(canmentionhereorinNecksection)
Radial:2/4bilaterally
Brachial:2/4bilaterally
Femoral:right2/4,left2/4
Popliteal:right2/4,left2/4
Posteriortibial:right1/4,left1/4
Dorsalispedis:right2/4,left2/4
Maneuvers:Allentestindicatescollateralcirculationinhandsbilaterally,withre
flushingwithin5seconds.

Pleaseincludeyoursuspecteddiagnosisforbothcasesgivenintheclasshandout,as
wellasabrief(13sentences)justificationforyourdiagnosis.(1pt)