Slipping Rib Syndrome
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Part 1 the Thorax ECA1 7/18/06 6:30 PM Page 2 ECA1 7/18/06 6:30 PM Page 3
ECA1 7/18/06 6:30 PM Page 1 Part 1 The Thorax ECA1 7/18/06 6:30 PM Page 2 ECA1 7/18/06 6:30 PM Page 3 Surface anatomy and surface markings The experienced clinician spends much of his working life relating the surface anatomy of his patients to their deep structures (Fig. 1; see also Figs. 11 and 22). The following bony prominences can usually be palpated in the living subject (corresponding vertebral levels are given in brackets): •◊◊superior angle of the scapula (T2); •◊◊upper border of the manubrium sterni, the suprasternal notch (T2/3); •◊◊spine of the scapula (T3); •◊◊sternal angle (of Louis) — the transverse ridge at the manubrio-sternal junction (T4/5); •◊◊inferior angle of scapula (T8); •◊◊xiphisternal joint (T9); •◊◊lowest part of costal margin—10th rib (the subcostal line passes through L3). Note from Fig. 1 that the manubrium corresponds to the 3rd and 4th thoracic vertebrae and overlies the aortic arch, and that the sternum corre- sponds to the 5th to 8th vertebrae and neatly overlies the heart. Since the 1st and 12th ribs are difficult to feel, the ribs should be enu- merated from the 2nd costal cartilage, which articulates with the sternum at the angle of Louis. The spinous processes of all the thoracic vertebrae can be palpated in the midline posteriorly, but it should be remembered that the first spinous process that can be felt is that of C7 (the vertebra prominens). The position of the nipple varies considerably in the female, but in the male it usually lies in the 4th intercostal space about 4in (10cm) from the midline. -
Signs and Symptoms of COPD
American Thoracic Society PATIENT EDUCATION | INFORMATION SERIES Signs and Symptoms of COPD Chronic obstructive pulmonary disease (COPD) can cause shortness of breath, tiredness, Short ness of Breath production of mucus, and cough. Many people with COPD develop most if not all, of these signs Avo iding Activities and symptoms. Sho rtness wit of Breath h Man s Why is shortness of breath a symptom of COPD? y Activitie Shortness of breath (or breathlessness) is a common Avoiding symptom of COPD because the obstruction in the A breathing tubes makes it difficult to move air in and ny Activity out of your lungs. This produces a feeling of difficulty breathing (See ATS Patient Information Series fact sheet Shor f B tness o on Breathlessness). Unfortunately, people try to avoid this reath Sitting feeling by becoming less and less active. This plan may or Standing work at first, but in time it leads to a downward spiral of: avoiding activities which leads to getting out of shape or becoming deconditioned, and this can result in even more Is tiredness a symptom of COPD? shortness of breath with activity (see diagram). Tiredness (or fatigue) is a common symptom in COPD. What can I do to treat shortness of breath? Tiredness may discourage you from keeping active, which leads to greater loss of energy, which then leads to more If your shortness of breath is from COPD, you can do several tiredness. When this cycle begins it is sometimes hard to things to control it: break. CLIP AND COPY AND CLIP ■■ Take your medications regularly. -
Structure of the Human Body
STRUCTURE OF THE HUMAN BODY Vertebral Levels 2011 - 2012 Landmarks and internal structures found at various vertebral levels. Vertebral Landmark Internal Significance Level • Bifurcation of common carotid artery. C3 Hyoid bone Superior border of thyroid C4 cartilage • Larynx ends; trachea begins • Pharynx ends; esophagus begins • Inferior thyroid A crosses posterior to carotid sheath. • Middle cervical sympathetic ganglion C6 Cricoid cartilage behind inf. thyroid a. • Inferior laryngeal nerve enters the larynx. • Vertebral a. enters the transverse. Foramen of C 6. • Thoracic duct reaches its greatest height C7 Vertebra prominens • Isthmus of thyroid gland Sternoclavicular joint (it is a • Highest point of apex of lung. T1 finger's breadth below the bismuth of the thyroid gland T1-2 Superior angle of the scapula T2 Jugular notch T3 Base of spine of scapula • Division between superior and inferior mediastinum • Ascending aorta ends T4 Sternal angle (of Louis) • Arch of aorta begins & ends. • Trachea ends; primary bronchi begin • Heart T5-9 Body of sternum T7 Inferior angle of scapula • Inferior vena cava passes through T8 diaphragm T9 Xiphisternal junction • Costal slips of diaphragm T9-L3 Costal margin • Esophagus through diaphragm T10 • Aorta through diaphragm • Thoracic duct through diaphragm T12 • Azygos V. through diaphragm • Pyloris of stomach immediately above and to the right of the midline. • Duodenojejunal flexure to the left of midline and immediately below it Tran pyloric plane: Found at the • Pancreas on a line with it L1 midpoint between the jugular • Origin of Superior Mesenteric artery notch and the pubic symphysis • Hilum of kidneys: left is above and right is below. • Celiac a. -
1 the Thoracic Wall I
AAA_C01 12/13/05 10:29 Page 8 1 The thoracic wall I Thoracic outlet (inlet) First rib Clavicle Suprasternal notch Manubrium 5 Third rib 1 2 Body of sternum Intercostal 4 space Xiphisternum Scalenus anterior Brachial Cervical Costal cartilage plexus rib Costal margin 3 Subclavian 1 Costochondral joint Floating ribs artery 2 Sternocostal joint Fig.1.3 3 Interchondral joint Bilateral cervical ribs. 4 Xiphisternal joint 5 Manubriosternal joint On the right side the brachial plexus (angle of Louis) is shown arching over the rib and stretching its lowest trunk Fig.1.1 The thoracic cage. The outlet (inlet) of the thorax is outlined Transverse process with facet for rib tubercle Demifacet for head of rib Head Neck Costovertebral T5 joint T6 Facet for Tubercle vertebral body Costotransverse joint Sternocostal joint Shaft 6th Angle rib Costochondral Subcostal groove joint Fig.1.2 Fig.1.4 A typical rib Joints of the thoracic cage 8 The thorax The thoracic wall I AAA_C01 12/13/05 10:29 Page 9 The thoracic cage Costal cartilages The thoracic cage is formed by the sternum and costal cartilages These are bars of hyaline cartilage which connect the upper in front, the vertebral column behind and the ribs and intercostal seven ribs directly to the sternum and the 8th, 9th and 10th ribs spaces laterally. to the cartilage immediately above. It is separated from the abdominal cavity by the diaphragm and communicates superiorly with the root of the neck through Joints of the thoracic cage (Figs 1.1 and 1.4) the thoracic inlet (Fig. -
Breathing Better with a COPD Diagnosis
Difficulty Breathing Chronic Bronchitis Smoker’s Cough Chronic Coughing Wheezing Em- Chronic Obstructive Pulmonary Disease physema Shortness of Breath Feeling of Suffocation Excess Mucus Difficulty Breathing Chronic Bronchitis Smoker’s Cough Chronic Coughing Wheezing Emphysema Shor tness of Breath Feeling of Suffocation Excess Mucus Difficulty Breathing Chronic Bronchitis Smoker’s Cough Chronic Coughing Wheezing Emphysema Shortness of Breath Feeling of Suffocation Excess Mucus Difficulty Breathing Chronic Bronchitis Smoker’s Cough Chron- ic Coughing Wheezing Emphysema Shortness of Breath Feeling of Suffocation Excess Mu- cus DifficultyBreathing Breathing Chronic Bronchitis Better Smoker’s Cough Chronic Coughing Wheezing Emphysema Shortness of Breath Feeling of Suffocation Excess Mucus Difficulty Breathing Chronic Bronchitis Smoker’s Cough Chronic Coughing Wheezing Emphysema Shor tness of Breath Feeling of SuffocationWith Excess a COPDMucus Difficulty Diagnosis Breathing Chronic Bronchitis Smoker’s Cough Chronic Coughing Wheezing Emphysema Shortness of Breath Feeling of did you know? When COPD is severe, shortness of breath and other COPDdid you is the know? 4th leading cause of death in the symptomswhen you can get are in the diagnosed way of doing even the most UnitedCOPD States.is the 4th The leading disease cause kills ofmore death than in 120,000 basicwith tasks, copd such as doing light housework, taking a Americansthe United eachStates year—that’s and causes 1 serious, death every long-term 4 walk,There and are even many bathing things and that getting you can dressed. do to make minutes—anddisability. The causesnumber serious, of people long-term with COPDdisability. is COPDliving withdevelops COPD slowly, easier: and can worsen over time, increasing.The number More of people than 12with million COPD people is increasing. -
Rivaroxaban (Xarelto®)
Rivaroxaban (Xarelto®) To reduce your bleeding and clotting risk it is important that you attend follow-up appointments with your provider, and have blood tests done as your provider orders. What is rivaroxaban (Xarelto®)? • Rivaroxaban is also called Xarelto® • Rivaroxaban(Xarelto®) is used to reduce the risk of blood clots and stroke in people with an abnormal heart rhythm known as atrial fibrillation, in people who have had a blood clot, or in people who have undergone orthopedic surgery. o Blood clots can block a blood vessel cutting off blood supply to the area. o Rarely, clots can break into pieces and travel in the blood stream, lodging in the heart (causing a heart attack), the lungs (causing a pulmonary embolus), or in the brain (causing a stroke). • If you were previously on Warfarin/Coumadin® and you are starting Rivaroxaban(Xarelto®), do not continue taking warfarin. Rivaroxaban(Xarelto®) replaces warfarin. Xarelto 10mg tablet Xarelto 15mg tablet Xarelto 20mg tablet How should I take rivaroxaban (Xarelto®)? • Take Rivaroxaban(Xarelto®) exactly as prescribed by your doctor. • Rivaroxaban(Xarelto®) should be taken with food. • Rivaroxaban(Xarelto®) tablets may be crushed and mixed with applesauce to make the tablet easier to swallow. - 1 - • If you missed a dose: o Take it as soon as you remember on the same day. • Do not stop taking rivaroxaban suddenly without telling your doctor. This can put you at risk of having a stroke or a blood clot. • If you take too much rivaroxaban, call your doctor or the anticoagulation service. If you are experiencing any bleeding which you cannot get to stop, go to the nearest emergency room. -
BREATHLESSNESS ABSTRACT INTRODUCTION Dyspnoea, Also
EMERGENCY MEDICINE – WHAT THE FAMILY PHYSICIAN CAN TREAT UNIT NO. 4 BREATHLESSNESS In one study of 85 patients presenting to a pulmonary unit Psychiatric conditions appropriate context of the history, physical examination, and ischaemia. Serial measurements of cardiac biomarkers are inhaler (MDI). In severe asthma, patients should be transferred breathlessness. In such cases, it is prudent to start therapies for with a complaint of chronic dyspnoea, the initial impression Psychogenic causes for acute dyspnoea is a diagnosis of the consideration of dierential diagnosis. Random testing necessary as initial results can often be normal. to ED for further treatment with nebulised ipratropium multiple conditions in the initial resuscitative phase. For Dr Pothiawala Sohil of the aetiology of dyspnoea based upon the patient history exclusion, and organic causes must be ruled out rst before without a clear dierential diagnosis will delay appropriate bromide, intravenous magnesium, ketamine, IM adrenaline, example, for a patient with a past medical history of COPD and alone was correct in only 66 percent of cases.4 us, a considering this diagnosis (e.g., panic attack).5 management. e use of dyspnoea biomarker panels does not Brain natriuretic peptide (BNP) intubation, and inhalational anaesthesia as needed. congestive cardiac failure, the initial management of sudden systematic approach, comprising of adequate history and appear to improve accuracy beyond clinical assessment and is is used to diagnose heart failure, but it can also be elevated onset of dyspnoea may include therapies directed at both these ABSTRACT diagnostic studies, and provide recommendations for initial physical examination, followed by appropriate investigations focused testing.6, 7 in uid overload secondary to renal failure. -
Review of Systems – Clinician Documentation Aug 2019
Review of Systems – Clinician Documentation Aug 2019 WHAT YOU NEED TO KNOW: Review of Systems (ROS) is an inventory of body systems obtained by asking a series of questions to identify signs and/or symptoms the patient may be experiencing or has experienced. CMS and Payers have varying documentation audit focal points for clinical validation of services rendered. Points are not synonymous with symptoms. What are the systems recognized 1. Constitutional Symptoms (for example: fever, weight loss) for ROS? 2. Eyes 3. Ears, nose, mouth, throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary What are the three types of ROS? 1. Problem pertinent 2. Extended 3. Complete What is required for each type 1. Problem Pertinent ROS inquires about the system directly related to the problem ROS? identified in the History of Physical Illness (HPI). 2. Extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number (two to nine) of additional systems. 3. Complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of ten) organ systems. You must individually document those systems with positive or pertinent negative responses. For the remaining systems, a notation indicating all other systems are negative is permissible. Documentation Requirements Documentation within the patient record should support the level of service billed. For every service billed, you must indicate the specific sign, symptom, or patient complaint that makes the service reasonable and medically necessary. It would be inappropriate and likely ruled not medically necessary to bill based on a full review of systems for a problem focused complaint. -
Pulmonary Vascular Complications of Liver Disease
American Thoracic Society PATIENT EDUCATION | INFORMATION SERIES Pulmonary Vascular Complications of Liver Disease People who have advanced liver disease can have complications Jaundice that affect the heart and lungs. It is not unusual for a person (yellow tint to skin with severe liver disease to have shortness of breath. Breathing and eyes) problems can occur because the person can’t take as big a breath due to large amounts of ascites (fluid in the abdomen) or pleural effusions (fluid build-up between the tissues that line the lung and chest) or a very large spleen and liver that pushes the diaphragm up. Breathing problems can also occur with Hepatomegaly liver disease from changes in the blood vessels and blood flow in the lungs. There are two well-recognized conditions that can result from liver disease: hepatopulmonary syndrome and portopulmonary hypertension. This fact sheet will review these Breathing two conditions and how they relate to liver disease. problems What is liver disease? the rest of your body. These toxins can damage blood vessels The liver is the second largest organ in the body and has many in your lungs leading to dilated (enlarged) or constricted important roles within the body including helping with digestion, (narrowed) vessels. Two different conditions can be seen in the metabolizing drugs, and storing nutrients. Its main job is to lungs that arise from liver disease: hepatopulmonary syndrome filter blood coming from the digestive tract and remove harmful and portopulmonary hypertension: CLIP AND COPY AND CLIP substances from it before passing it to the rest of the body. -
Subcostal TAP, Rectus Sheath
Station 4: Traditional Transversus Abdominis Plane (TAP), Subcostal TAP, Rectus Sheath Station Faculty: Traditional TAP: Adam Amundson, MD David Olsen, MD Indications: o Surgeries that involve the lower abdominal segment (below umbilicus) ie: Pfannenstiel incision for cesarean-section. Ultrasound settings and Patient Position o High Frequency linear probe; Low Frequency linear probe if morbidly obese (38-50 mm footprint) o Supine, arms to sides, performed with patient either sedated or under general anesthesia Surface Anatomy landmarks o Rib cage, costal margin o Iliac Crest, pelvic brim o Mid-axillary line Sonoanatomy – o Start by placing the ultrasound probe between the iliac crest and costal margin at the mid-axillary line o Identify the 3 muscular layers (external oblique EO, internal oblique IO, transversus abdominis TA) and the peritoneum o TIPS: EO is generally hyperechoic, IO is the largest, TA is thin, Bowel/Peritoneum may move EO EO IO IO Superior Superior TA TA Bowel Bowel Suggested Injection Technique- TA o In-plane short axis approach, sonographically guide a 21 g 4 inch needle in between the fascial plane of the IO and TA in the posterior corner (see white arrow below). o Inject 20 mL of dilute long acting local anesthetic per side, or 30 mL if unilateral EO EO IO IO Superior Superior TA Bowel Bowel Bowel o TIP: When entering fascial planes between IO and TA the needle tip is often positioned deep and you may need to slowly pull the needle back while giving small aliquots of fluid to help define the spread of the fascial planes. -
Types of Chest Pain Table
Types of Chest Pain This table explains some of the common causes, signs and symptoms of chest pain. Please remember that this information is a guide only. DO NOT USE FOR DIAGNOSIS. If symptoms persist, or you become unsure or concerned, please speak with your doctor. Name Cause of chest pain Symptoms of chest pain Location of pain How to relieve chest pain Angina Angina occurs when there isn't discomfort May be felt in the centre of Rest enough oxygen-rich blood flowing to tightness the chest or across the Anginine – dissolved part of your heart. Angina is caused pressure chest, into the throat or jaw, under the tongue by narrowed coronary arteries. squeezing down the arms, between the or heaviness shoulder blades Nitrolingual spray- dull ache Unstable angina may be sprayed under the unrelated to activity or Additional symptoms may include: tongue stress, comes on more nausea shortness of breath frequently or takes longer to strange feeling or ease tingling/numbness in the Angina symptoms can neck, back, arm, jaw or gradually get worse over 2 to 5 shoulders minutes. Angina usually lasts less light headedness than 15 minutes irregular heart beat Heart Attack A heart attack happens when plaque similar to angina however unable to pinpoint exact A heart attack is a cracks inside the narrowed coronary last longer than 15 minutes spot medical emergency. artery - causing a blood clot to form. and are not relieved by rest, May be felt in the centre of If the blood clot totally blocks the Anginine or Nitrolingual the chest or across the If pain is not relieved by artery, the heart muscle becomes spray chest, into the throat or jaw, Anginine or Nitrolingual damaged Additional symptoms may include: down the arms, between the spray in 10 to 15 minutes, nausea shoulder blades call 000 for an vomiting ambulance. -
Know the Warning Signs of a Heart Attack
Toolkit No. 22 Know the Warning Signs of a Heart Attack What is a heart attack? A heart attack happens when the blood vessels that go to your heart get blocked by fatty deposits or a blood clot. When this happens, the blood supply is reduced or cut off. Then oxygen and other materials can’t get through to your heart , hurting your heart muscle. Another name for a heart attack is myocardial infarction, or MI. If you have diabetes, you’re at risk for a heart attack. What are the warning signs of a heart attack? The warning signs include • chest pain or discomfort, tightness, pressure, or fullness. Call 9-1-1 right away if you have warning signs of This might feel like indigestion or heartburn. a heart attack. Getting help can help save your life. • discomfort in one or both of your arms, your back, jaw, neck, or stomach • shortness of breath • help blood flow in your heart • sweating • reduce chest pain • indigestion or nausea or vomiting These steps work best within an hour of the first warning • tiredness, fainting, or feeling light-headed signs of a heart attack. You may not have all of these signs, and they may come How are the signs of a heart attack and go. The most common warning sign for both men and women is chest pain. But women are more likely to different for people with diabetes? have some of the other warning signs. If you have chest Diabetes can affect your nerves and make heart attacks pain that doesn’t go away after you rest for a few painless or “silent.” A silent heart attack means that you minutes , you might be having a heart attack.