DOCSLIB.ORG

The Value of Praecordialpulsations in the Diagnosis of Heart Disease

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
The Value of Praecordialpulsations in the Diagnosis of Heart Disease Postgrad Med J: first published as 10.1136/pgmj.44.507.81 on 1 January 1968. Downloaded from Festschrift for Sir John McMichael 81 References KOPELMAN, H., ROBERTSON, M.H., SANDERS, P.G. & ASH, I. ANON. (1966) Editorial: Toxic bread. J. Amer. med. Ass. 196, (1966a) The Epping Jaundice. Brit. med. J. i, 514. 1150. KOPELMAN, H., SCHEUER, P.J. & WILLIAMS, R. (1966b) The CHUTTARI, H.K., SIDHU, WIG, K.L., GUPTA, D.N., RAMA- liver lesion of the Epping LINGASWAMI, V. (1966) Follow-up study of cases from the Jaundice. Quart. J. Med. 25, 553. Delhi epidemic of infectious hepatitis, 1955-56. Brit. med. SHERLOCK, S. & WALSHE, V.M. (1946) The post-hepatitis J. ii, 676. syndrome. Lancet, ii, 482. The value of praecordial pulsations in the diagnosis of heart disease PATRICK MOUNSEY Royal Postgraduate Medical School, London PALPATION of the praecordium is as indispensable relation to a fixed point in space. Various as auscultation of the heart in clinical examina- methods have been used for making this mea- tion of the cardiac patient. Indeed, the two surement, by Dressler in 1937, Eddleman et al. should be practised simultaneously, checking the in 1953 and by Beilin & Mounsey in 1962. We timing of heart sounds and praecordial move- have called our instrument the impulse cardio- ments in relation to one another. To some ex- gram and it aims at being a graphic record of tent the introduction of the modern binaural what the physician's hand and fingers feel. stethoscope with its flexible rubber tubes has by copyright. been a retrograde step, since this instrument is less suited to simultaneous analysis of praecordial The technique of palpating the praecordium pulsations and heart sounds than was the original It is often a good practice when examining the solid tubular stethoscope invented by Laennec. praecordium to place the whole palm of the In the Traite de l'Auscultation Mediate, Laennec hand over the area of the chest that underlies (1819) emphasized that his instrument could be the heart. In this way, one can imagine that one used not only to auscultate the heart but also is holding the anterior surface of the heart in to appreciate accurately the cardiac impulse. He the cup of one's hand, thus appreciating both includes in his book a chapter on the cardiac right and left heart events simultaneously. Care impulse and states that a forcible impulse should should be taken, however, not to assume that http://pmj.bmj.com/ be regarded as the principle sign of cardiac pulsations at the apex are always due to the left hypertrophy. ventricle, while those in the left parasternal area Improved methods of recording the cardiac are due to the right. Although this state- impulse have been slower to develop than has ment is true probably in about 90% of patients, phonocardiography, although apex cardiography in the other 10% it is misleading. With great was one of the earliest methods introduced for enlargement of either left or right ventricle the recording the heart beat (Marey, 1878). Apex of relationship underlying chambers of the heart on October 2, 2021 by guest. Protected cardiography suffers from the disadvantage that to the praecordium are altered (Fig. 1). Thus, it is only a record of the relative displacement with marked left ventricular hypertrophy this of a point in an intercostal space in relation to chamber may underlie the whole area of prae- the immediately surrounding area of chest wall. cordium from the apex beat to the left sternal In cardiac diagnosis it is often the displacement edge, the right ventricle being pushed over to of a large area of the thoracic cage by the the right. Similarly, with great right ventricular movements of the underlying heart that is im- enlargement this chamber forms the apex of the portant diagnostically, (as in the left parasternal heart, the left ventricle being rotated posteriorly lift of right ventricular hypertrophy), and not (Deliyannis et al., 1964). It is more accurate, the relative movement of a small area in an therefore, when describing praecordial pulsations intercostal space. To record this, an instrument to relate these to the areas on the chest wall is required that measures absolute displacement, where they are felt, rather than to term them that is the total movement of the chest wall in 'right or left ventricular types' of impulse. F Postgrad Med J: first published as 10.1136/pgmj.44.507.81 on 1 January 1968. Downloaded from 82 Postgraduate Medical Journal (a) (b) (c) FIG. 1. Superimposed tracings of right (dotted line) and left (solid line) ventricular angiocardiograms of (a) normal subject with functional systolic murmur. The apex beat (black dot) lies 2 cm lateral to the right ven- tricular cavity and overlies the antero-septal ventricular wall. (b) Patient with left ventricular hypertrophy from mitral incompetence. The apex beat (black dot) overlies the antero-lateral wall of the left ventricle; the left para- sternal area overlies its antero-septal ventricular wall. (c) Patient with right ventricular hypertrophy from pulmonary hypertension and ventricular septal defect. The apex beat (black dot) in the fourth intercostal space, 7 cm to the left of the mid line, overlies the anterior wall of the right ventricle. The left parasternal area overlies the more medial portion of the anterior wall of the right ventricle. The interventricular septum lies in the coronal plane, with the left ventricle rotated posteriorly. (Antero-posterior views.) The genesis of the cardiac impulse in health and 1. The apical impulse in ventricular systole disease The first part of the apical impulse, both in Angiocardiographic and cinefluoroscopic health and disease, is probably caused by similar by copyright. studies have shown close correlation between the mechanisms. In William Harvey's words (1628), movements of the heart and the form of the 'the heart erects and raises itself into a point, cardiac impulse. so that at this moment it strikes the chest wall http://pmj.bmj.com/ EJECT%ION ;-ATE EJECT!ON j on October 2, 2021 by guest. Protected ..T ... W__,~~~ .. i .W_i_W~~ FIG. 2. Left ventricular angiocardiograms (lateral view) of patient with small ventricular septal defect; in diastole (left) and in late systole (right). In line diagram, interrupted lines indicate diastolic, and solid line indicates late systolic cavity-wall positions. Apical retraction demonstrated in late systole coinciding with retraction in impulse cardiogram. Postgrad Med J: first published as 10.1136/pgmj.44.507.81 on 1 January 1968. Downloaded from Festschrift for Sir John McMichael 83 ..lLY... LAT EJECT(t FIG. 3. Left ventricular angiocardiograms (lateral view) of patient with aortic and mitral incompetence; in diastole (left) and in late systole (right). In line diagram, interrupted lines indicate diastolic, and solid line indicates late systolic cavity-wall positions. Apical portion of heart fails to retract in late systole, thus accounting for sustained, thrusting apical impulse. and externally a pulsation can be felt'. It is dur- trophy, thus tending to inhibit the apical re- ing the latter part of systole that the heart be- tracting action of the spiral fibres (Fig. 4) haves abnormally in the presence of hypertrophy. (Deliyannis et al., 1964). Other factors, however, Whereas in health the anterior wall of the heart probably also contribute to the genesis of the retracts from the thoracic cage as the heart sustained impulse including general increase in by copyright. empties in late systole (Fig. 2), in left ventricular heart size and sometimes dilatation as well as hypertrophy the antero-apical portion of the hypertrophy. heart fails to retract in late systole (Fig. 3), thus The cause of the sustained impulse in ventri- giving rise to the sustained cardiac impulse felt cular aneurysm is not far to seek. The aneurys- over the praecordium. Studies of the different mal wall which is composed entirely of fibrous muscle layers of the heart have suggested that tissue without any living myocardium, is unable the cause of this phenomenon is extension of the to take part in concentric contraction of the middle circular layer of muscle fibres toward heart and herniates outwards during ventricular the apex of the heart in the presence of hyper- systole (Fig. 5). The marked systolic retraction and diastolic Normal heort Hypertrophied heart expansion seen in some cases of constrictive http://pmj.bmj.com/ pericarditis is probably related to tethering of Aorta ~ Aota ~tro tra the inflow and outflow tracts of the ventricles, rinA in annular constrictive pericarditis (Fig. 6). In this condition, the anterior wall of the ventricles is often relatively free from constriction and Circular hence shows exaggerated contraction during w 7~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~n ventricular systole and expansion during dia- 4 ~~~~~~~~Circular ~ stole. Ventricular filling is abnormally abrupt on October 2, 2021 by guest. Protected and forceful due to the high venous filling pres- LV LV sure. The marked systolic retraction and large Apex Apex diastolic rapid inflow beat seen in the impulse cardiogram closely reflect the underlying heart FIG. 4. Schema of forces resulting from contraction of middle circular and of spiral fasciculi of left ventricle. wall movements (Mounsey, 1959). In health, the middle circular fasciculus constricts the Apical retraction seen in tricuspid incompet- upper portion ofthe heart, while the relatively unopposed ence is due to a different mechanism, reflecting spiral fibres retract the apex. In left ventricular hyper- the increased stroke output of the dilated right trophy the widened middle circular fasciculus extends further toward the apex, thus tending to inhibit the ventricle which is both ejecting blood into the apical retracting action of the spiral fasciculus. pulmonary artery and regurgitating it through Postgrad Med J: first published as 10.1136/pgmj.44.507.81 on 1 January 1968.
Load more

Recommended publications
  • Practical Cardiac Auscultation
    LWW/CCNQ LWWJ306-08 March 7, 2007 23:32 Char Count= Crit Care Nurs Q Vol. 30, No. 2, pp. 166–180 Copyright c 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins Practical Cardiac Auscultation Daniel M. Shindler, MD, FACC This article focuses on the practical use of the stethoscope. The art of the cardiac physical exam- ination includes skillful auscultation. The article provides the author’s personal approach to the patient for the purpose of best hearing, recognizing, and interpreting heart sounds and murmurs. It should be used as a brief introduction to the art of auscultation. This article also attempts to illustrate heart sounds and murmurs by using words and letters to phonate the sounds, and by presenting practical clinical examples where auscultation clearly influences cardiac diagnosis and treatment. The clinical sections attempt to go beyond what is available in standard textbooks by providing information and stethoscope techniques that are valuable and useful at the bedside. Key words: auscultation, murmur, stethoscope HIS article focuses on the practical use mastered at the bedside. This article also at- T of the stethoscope. The art of the cardiac tempts to illustrate heart sounds and mur- physical examination includes skillful auscul- murs by using words and letters to phonate tation. Even in an era of advanced easily avail- the sounds, and by presenting practical clin- able technological bedside diagnostic tech- ical examples where auscultation clearly in- niques such as echocardiography, there is still fluences cardiac diagnosis and treatment. We an important role for the hands-on approach begin by discussing proper stethoscope selec- to the patient for the purpose of evaluat- tion and use.
    [Show full text]
  • Auscultation of Abdominal Arterial Murmurs
    Auscultation of abdominal arterial murmurs C. ARTHUR MYERS, D.O.,° Flint, Michigan publications. Goldblatt's4 work on renal hyperten- sion has stimulated examiners to begin performing The current interest in the diagnostic value of ab- auscultation for renal artery bruits in their hyper- dominal arterial bruits is evidenced by the number tensive patients. of papers and references to the subject appearing in Stenosis, either congenital or acquired, and aneu- the recent literature. When Vaughan and Thoreki rysms are responsible for the vast majority of audi- published an excellent paper on abdominal auscul- ble renal artery bruits (Fig. 2). One should be tation in 1939, the only reference they made to highly suspicious of a renal artery defect in a hy- arterial murmurs was that of the bruit of abdominal pertensive patient with an epigastric murmur. Moser aortic aneurysm. In more recent literature, however, and Caldwell5 have produced the most comprehen- there is evidence of increased interest in auscultat- sive work to date on auscultation of the abdomen ing the abdomen for murmurs arising in the celiac, in renal artery disease. In their highly selective superior mesenteric, splenic, and renal arteries. series of 50 cases of abdominal murmurs in which The purpose of this paper is to review some of aortography was performed, renal artery disease the literature referable to the subject of abdominal was diagnosed in 66 per cent of cases. Their con- murmurs, to present some cases, and to stimulate clusions were that when an abdominal murmur of interest in performing auscultation for abdominal high pitch is found in a patient with hypertension, bruits as a part of all physical examinations.
    [Show full text]
  • Intra-Operative Auscultation of Heart and Lungs Sounds: the Importance of Sound Transmission
    Intra-Operative Auscultation of more readily when stethoscopes are used. Loeb Heart and Lungs Sounds: (2) has reported that the response time to detect an abnormal value on an intraoperative The Importance of Sound monitor display and it was 61 seconds with 16% Transmission of the abnormal values not being recognized in 5 minutes. Whereas, Copper et al, (3) found the Anthony V. Beran, PhD* meantime between an event and detection with a stethoscope was 34 seconds. This Introduction suggests that changes in cardio-pulmonary function may be detected more readily with a Sometimes we put so much emphasis on stethoscope (1). Auscultation of heart and lung electronic monitoring devices we forget that sounds during perioperative period is useful our own senses often detect things before a only if the Esophageal Stethoscope provides machine can. Seeing condensation in airway strong, clear transmission of the sounds to the device or clear mask can serve to indicate the anesthesia provider. This study evaluates the presence of ventilation before the signal has sound transmission properties of several even reached the equipment. Sometimes the Esophageal Stethoscopes currently available in sense of smell can be the first thing to aid in the the market. detection of a disconnected airway device or circuit. Similarly, in some situations listening for Methods the presence of abnormal heart or airway sounds can help detect the onset of critical To evaluate the sound transmission properties incidents quicker than electronic monitors. But of the Esophageal Stethoscopes in vitro study in recent years the art of listening has changed was performed. A system that simulates the in the practice of Anesthesia.
    [Show full text]
  • 1. Intermittent Chest Pain: Angina: • Stable: (Caused By
    CVS: 1. Intermittent chest pain: Angina: • Stable: (caused by chronic narrowing in one or more coronary arteries), episodes of pain are precipitated by exertion and may occur more readily when walking in cold or windy weather, after a large meal or while carrying a heavy load; the pain is promptly relieved by rest and/or sublingual glyceryl nitrate (GTN) spray, and typically lasts for less than 10 minutes. • unstable angina (caused by a sudden severe narrowing in a coronary artery), there is usually an abrupt onset or worsening of chest pain episodes that may occur on minimal exertion or at rest. • Retrosternal/ Progressive onset/ increase in intensity over 1–2 minutes/ Constricting, heavy/ Sometimes arm(s), neck, epigastrium/ Associated with breathlessness/ Intermittent, with episodes lasting 2–10 minutes/ Triggered by emotion, exertion, especially if cold, windy/ Relieved by rest, nitrates Mild to moderate. • Aggravated by thyroxine or drug-induced anemia, e.g. aspirin or NSAIDs Esophageal: • Retrosternal or epigastric/ Over 1–2 minutes; can be sudden (spasm)/ C: Gripping, tight or burning/ R: Often to back, sometimes to arms/ A: Heartburn, acid reflux/ T: Intermittent, often at night-time; variable duration/ Lying flat/some foods may trigger/ Not relieved by rest; nitrates sometimes relieve/ Usually mild but esophageal spasm can mimic myocardial infarction. 2. Acute chest pain: MI: • SOCRATES: Retrosternal/ Rapid over a few minutes/ Constricting, heavy/ Often to arm(s), neck, jaw, sometimes epigastrium/ Sweating, nausea, vomiting, breathlessness, feeling of impending death (angor animi)/ Acute presentation; prolonged duration/ ’Stress’ and exercise rare triggers, usually spontaneous/ Not relieved by rest or nitrates/ Usually severe.
    [Show full text]
  • Scoliosis, Alters the Position of the Beat
    Br Heart J: first published as 10.1136/hrt.8.3.162 on 1 July 1946. Downloaded from THE HEART IN STERNAL DEPRESSION BY WILLIAM EVANS From the Cardiac Department ofthe London Hospital Received June 25, 1946 The place where the apex beat appears on the chest wall depends as much on the symmetry of the thorax as on the size of the heart. A change in the alignment of the spine, the posterior fulcrum of the thoracic cage, in the form of scoliosis, alters the position of the beat. Local deformity of the ribs which form the walls of the cage will do the same thing. Deformity of the sternum, the anterior fulcrum of the thorax, as a cause of displacement of the apex beat has received less attention. The effects of depression of the sternum (pectus excavatum) on the shape and position of the heart have been studied in sixteen adults examined during the past year. DESCRIPTION OF CASES All sixteen patients had been referred for an explanation of certain signs connected with the heart, with the knowledge that deformity of the chest was present, but without appreciating that the two conditions might be related. In many of them suspicion of heart disease had led to restriction of their physical activities and to a change of design for their future livelihood. The symptoms that had caused the patients to seek medical advice in the first place were http://heart.bmj.com/ TABLE I SUMMARY OF FINDNGS IN 16 HEALTHY SUBJECTS WITH DEPRESSED STERNUM Antero-posterior Radiological findings in anterior view chest measurement _ _ Case Age Sternal in inches No.
    [Show full text]
  • 5 Precordial Pulsations
    Chapter 5 / Precordial Pulsations 113 5 Precordial Pulsations CONTENTS MECHANICS AND PHYSIOLOGY OF THE NORMAL APICAL IMPULSE PHYSICAL PRINCIPLES GOVERNING THE FORMATION OF THE APICAL IMPULSE NORMAL APICAL IMPULSE AND ITS DETERMINANTS ASSESSMENT OF THE APICAL IMPULSE LEFT PARASTERNAL AND STERNAL MOVEMENTS RIGHT PARASTERNAL MOVEMENT PULSATIONS OVER THE CLAVICULAR HEADS PULSATIONS OVER THE SECOND AND/OR THIRD LEFT INTERCOSTAL SPACES SUBXIPHOID IMPULSE PRACTICAL POINTS IN THE CLINICAL ASSESSMENT OF PRECORDIAL PULSATIONS REFERENCES In this chapter the pulsations of the precordium will be discussed in relation to their identification, the mechanisms of their origin, and their pathophysiological and clinical significance. Precordial pulsations include the “apical impulse,” left parasternal movement, right parasternal movement, pulsations of the clavicular heads, pulsations over the second left intercostal space, and subxiphoid impulses. MECHANICS AND PHYSIOLOGY OF THE NORMAL APICAL IMPULSE Since during systole the heart contracts, becoming smaller and therefore moving away from the chest wall, why should one feel a systolic outward movement (the apical impulse) at all? Logically speaking there should not be an apical impulse. Several different methods of recording the precordial motion have been used to study the apical impulse going back to the late 19th century (1,2). Among the more modern methods, the notable ones are the recordings of the apexcardiogram (3–17), the impulse cardiogram (18), and the kinetocardiogram (19–21). While apexcardiography records the relative displacement of the chest wall under the transducer pickup device, which is often held by the examiner’s hands, the proponents of the impulse cardiography and kinetocardiography point out that these methods allow the recording of the absolute movement of the chest wall because the pickup device is anchored to a fixed point held 113 114 Cardiac Physical Examination in space away from the chest.
    [Show full text]
  • Jugular Venous Pressure
    NURSING Jugular Venous Pressure: Measuring PRACTICE & SKILL What is Measuring Jugular Venous Pressure? Measuring jugular venous pressure (JVP) is a noninvasive physical examination technique used to indirectly measure central venous pressure(i.e., the pressure of the blood in the superior and inferior vena cava close to the right atrium). It is a part of a complete cardiovascular assessment. (For more information on cardiovascular assessment in adults, see Nursing Practice & Skill ... Physical Assessment: Performing a Cardiovascular Assessment in Adults ) › What: Measuring JVP is a screening mechanism to identify abnormalities in venous return, blood volume, and right heart hemodynamics › How: JVP is determined by measuring the vertical distance between the sternal angle and the highest point of the visible venous pulsation in the internal jugular vein orthe height of the column of blood in the external jugular vein › Where: JVP can be measured in inpatient, outpatient, and residential settings › Who: Nurses, nurse practitioners, physician assistants, and treating clinicians can measure JVP as part of a complete cardiovascular assessment What is the Desired Outcome of Measuring Jugular Venous Pressure? › The desired outcome of measuring JVP is to establish the patient’s JVP within the normal range or for abnormal JVP to be identified so that appropriate treatment may be initiated. Patients’ level of activity should not be affected by having had the JVP measured ICD-9 Why is Measuring Jugular Venous Pressure Important? 89.62 › The JVP is
    [Show full text]
  • The Carotid Bruit on September 25, 2021 by Guest
    AUGUST 2002 221 Pract Neurol: first published as 10.1046/j.1474-7766.2002.00078.x on 1 August 2002. Downloaded from INTRODUCTION When faced with a patient who may have had a NEUROLOGICAL SIGN stroke or transient ischaemic attack (TIA), one needs to ask oneself some simple questions: was the event vascular?; where was the brain lesion, and hence its vascular territory?; what was the cause? A careful history and focused physical examination are essential steps in getting the right answers. Although one can learn a great deal about the state of a patient’s arteries from expensive vascular imaging techniques, this does not make simple auscultation of the neck for carotid bruits redundant. In this brief review, we will therefore defi ne the place of the bruit in the diagnosis and management of patients with suspected TIA or stroke. WHY ARE CAROTID BRUITS IMPORTANT? A bruit over the carotid region is important because it may indicate the presence of athero- sclerotic plaque in the carotid arteries. Throm- boembolism from atherosclerotic plaque at the carotid artery bifurcation is a major cause of TIA and ischaemic stroke. Plaques occur preferentially at the carotid bifurcation, usually fi rst on the posterior wall of the internal carotid artery origin. The growth of these plaques and their subsequent disintegration, surface ulcera- tion, and capacity to throw off emboli into the Figure 1 Where to listen for a brain and eye determines the pattern of subse- bifurcation/internal carotid quent symptoms. The presence of an arterial http://pn.bmj.com/ artery origin bruit – high up bruit arising from stenosis at the origin of the under the angle of the jaw.
    [Show full text]
  • Heart Sounds Nursing Documentation
    Heart Sounds Nursing Documentation Laurens guggling animally as smeary Benjamin indorse her railes slats uncommon. If unascendable or tawie Manny usually enamors his horsebacks descry pugilistically or realised poutingly and commensurately, how unitary is Yehudi? Is Ismail always chokey and knightly when break-wind some hylomorphism very perpendicularly and unpatriotically? Describe normal position brings out of nursing documentation the absence of the pulmonic valve prolapse Examples where nursing documentation of sound occurs is documented when one of. Inspect the heart? The infant visually inspected among male clients may create an actual age, understand that is then immediately upon palpation. Her master important. It is documented accurately on heart sounds from the nurse documents to carry out local work area located near the rest along imaginary line until balloon. The sounds documented when that are not allowed entry in right ventricle is eliciting slight tapping sensation in children and know how useful as described as. It hurts more than these generally determined. The heart are more firmly against bacterial endocarditis. Compare respiratory disease in cardiac asthma, have diagnosed heart defects that includes level of maximal contribution. Using these characteristics included inr and the hard to decompress the expiratory grunting, heart sounds nursing documentation of social assessment? The heart and documented every client for the body parts of tenderness of scaphoid, in an automatic muscular responses. Objective data and elevated for example: many reasons for? They are heart sound is. Blood passes through nursing documentation of heart failure of each ventricular ejection click is documented. Some heart sound detected points carried out from nursing documentation by inspection, document are documented a physical exam of breath sounds are more.
    [Show full text]
  • CARDIOLOGY Section Editors: Dr
    2 CARDIOLOGY Section Editors: Dr. Mustafa Toma and Dr. Jason Andrade Aortic Dissection DIFFERENTIAL DIAGNOSIS PATHOPHYSIOLOGY (CONT’D) CARDIAC DEBAKEY—I ¼ ascending and at least aortic arch, MYOCARDIAL—myocardial infarction, angina II ¼ ascending only, III ¼ originates in descending VALVULAR—aortic stenosis, aortic regurgitation and extends proximally or distally PERICARDIAL—pericarditis RISK FACTORS VASCULAR—aortic dissection COMMON—hypertension, age, male RESPIRATORY VASCULITIS—Takayasu arteritis, giant cell arteritis, PARENCHYMAL—pneumonia, cancer rheumatoid arthritis, syphilitic aortitis PLEURAL—pneumothorax, pneumomediasti- COLLAGEN DISORDERS—Marfan syndrome, Ehlers– num, pleural effusion, pleuritis Danlos syndrome, cystic medial necrosis VASCULAR—pulmonary embolism, pulmonary VALVULAR—bicuspid aortic valve, aortic coarcta- hypertension tion, Turner syndrome, aortic valve replacement GI—esophagitis, esophageal cancer, GERD, peptic OTHERS—cocaine, trauma ulcer disease, Boerhaave’s, cholecystitis, pancreatitis CLINICAL FEATURES OTHERS—musculoskeletal, shingles, anxiety RATIONAL CLINICAL EXAMINATION SERIES: DOES THIS PATIENT HAVE AN ACUTE THORACIC PATHOPHYSIOLOGY AORTIC DISSECTION? ANATOMY—layers of aorta include intima, media, LR+ LRÀ and adventitia. Majority of tears found in ascending History aorta right lateral wall where the greatest shear force Hypertension 1.6 0.5 upon the artery wall is produced Sudden chest pain 1.6 0.3 AORTIC TEAR AND EXTENSION—aortic tear may Tearing or ripping pain 1.2–10.8 0.4–0.99 produce
    [Show full text]
  • Chest Auscultation: Presence/Absence and Equality of Normal/Abnormal and Adventitious Breath Sounds and Heart Sounds A
    Northwest Community EMS System Continuing Education: January 2012 RESPIRATORY ASSESSMENT Independent Study Materials Connie J. Mattera, M.S., R.N., EMT-P COGNITIVE OBJECTIVES Upon completion of the class, independent study materials and post-test question bank, each participant will independently do the following with a degree of accuracy that meets or exceeds the standards established for their scope of practice: 1. Integrate complex knowledge of pulmonary anatomy, physiology, & pathophysiology to sequence the steps of an organized physical exam using four maneuvers of assessment (inspection, palpation, percussion, and auscultation) and appropriate technique for patients of all ages. (National EMS Education Standards) 2. Integrate assessment findings in pts who present w/ respiratory distress to form an accurate field impression. This includes developing a list of differential diagnoses using higher order thinking and critical reasoning. (National EMS Education Standards) 3. Describe the signs and symptoms of compromised ventilations/inadequate gas exchange. 4. Recognize the three immediate life-threatening thoracic injuries that must be detected and resuscitated during the “B” portion of the primary assessment. 5. Explain the difference between pulse oximetry and capnography monitoring and the type of information that can be obtained from each of them. 6. Compare and contrast those patients who need supplemental oxygen and those that would be harmed by hyperoxia, giving an explanation of the risks associated with each. 7. Select the correct oxygen delivery device and liter flow to support ventilations and oxygenation in a patient with ventilatory distress, impaired gas exchange or ineffective breathing patterns including those patients who benefit from CPAP. 8. Explain the components to obtain when assessing a patient history using SAMPLE and OPQRST.
    [Show full text]
  • History & Physical Format
    History & Physical Format SUBJECTIVE (History) Identification name, address, tel.#, DOB, informant, referring provider CC (chief complaint) list of symptoms & duration. reason for seeking care HPI (history of present illness) - PQRST Provocative/palliative - precipitating/relieving Quality/quantity - character Region - location/radiation Severity - constant/intermittent Timing - onset/frequency/duration PMH (past medical /surgical history) general health, weight loss, hepatitis, rheumatic fever, mono, flu, arthritis, Ca, gout, asthma/COPD, pneumonia, thyroid dx, blood dyscrasias, ASCVD, HTN, UTIs, DM, seizures, operations, injuries, PUD/GERD, hospitalizations, psych hx Allergies Meds (Rx & OTC) SH (social history) birthplace, residence, education, occupation, marital status, ETOH, smoking, drugs, etc., sexual activity - MEN, WOMEN or BOTH CAGE Review Ever Feel Need to CUT DOWN Ever Felt ANNOYED by criticism of drinking Ever Had GUILTY Feelings Ever Taken Morning EYE OPENER FH (family history) age & cause of death of relatives' family diseases (CAD, CA, DM, psych) SUBJECTIVE (Review of Systems) skin, hair, nails - lesions, rashes, pruritis, changes in moles; change in distribution; lymph nodes - enlargement, pain bones , joints muscles - fractures, pain, stiffness, weakness, atrophy blood - anemia, bruising head - H/A, trauma, vertigo, syncope, seizures, memory eyes- visual loss, diplopia, trauma, inflammation glasses ears - deafness, tinnitis, discharge, pain nose - discharge, obstruction, epistaxis mouth - sores, gingival bleeding, teeth,
    [Show full text]