Despite wondrous technologic advances, the physical examination remains the cornerstone of the evaluation process for any patient referred to Cincinnati Children's Heart Institute. We perform the evaluation in a patient- and family-centered manner so there is active engagement of not only our staff, but also our families and patients.
Process of the Physical Exam
A thorough history often precedes the physical examination and allows the cardiology staff to determine the reason for referral, significant family and medical history, and symptomatic status with respect to the cardiovascular system. Various members of the staff conduct the history and physical exam. They include the nurse, the nurse practitioner, the cardiology fellow (a doctor receiving training in pediatric cardiology) and the attending cardiology physician. At times, resident physicians and medical students may be involved.
The history also provides the first interaction of our staff with the patient's family so that some familiarity can be achieved prior to the performance of the physical examination. The family’s and patient’s personal interests will be explored by the providers. Families and patients are encouraged to do the same with their providers.
The history is likely to vary somewhat based not only on the age of the patient, but also on the reason for referral.
A detailed history also allows us to tailor the physical examination and, if needed, subsequent testing to deal precisely and thoroughly with the patient's suspected problem.
The first portion of the physical examination is performed by the screening clinic nurse. Height, weight, blood pressure and oxygen saturation determinations are made in the clinic at the time of being checked into the examination room.
Although these tests are painless, on occasion smaller children are anxious about blood pressure and pulse oximetry.
Rarely, however, are these tests difficult to obtain. The physical examination performed by the staff can be broken down into three separate parts, all of which are important in the accurate assessment of the patient.
- Observation: The simple act of observing a patient is often very revealing. Patients are observed for their general sense of distress / discomfort, possible associated abnormalities (for example, orthopedic deformities or Down syndrome) and for any more subtle abnormalities that might be a clue to more serious underlying heart disease, for example, cyanosis or chest asymmetry.
- Palpation (examination by touching): Using the fingers and hands, the physician in the clinic can gain insight into peripheral circulation (arms and legs) as well as overall heart muscle performance. Signs of peripheral fluid buildup (edema) can also be noted.
The chest is often palpated to determine the location of the heart and its overall degree of activity.
Additionally, some murmurs often create a loud enough noise to be felt through the chest, and the location of these "thrills" can pinpoint a structural heart abnormality.
- Auscultation (examination by listening): The final portion of the physical examination involves the use of the stethoscope to listen to various sounds that a heart makes.
During the auscultation process, valve closure and opening sounds are determined. We attempt to determine how many valve closure sounds there are, how loud they are, and where they are best heard.
Heart murmurs are characterized by timing in the heart cycle, loudness, pitch, and location. The entire chest and often the back are inspected with the stethoscope during this process.
In addition, extra sounds such as rubs, gallops and clicks are listened for. These, if present, can lead to a precise bedside diagnosis of a cardiac abnormality.
Finally, the lungs and abdomen are examined both by auscultation and palpation so as to determine position and size of abdominal organs, abnormal lung findings and possible murmurs in the abdomen or back.
During the course of the physical examination process, the pulse rate (heart rate) and respiratory rate are determined often by several observers.