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CCE Lecture Mid Term

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Problem Oriented Record – 4 parts
1. Database
2. Assessment of Database
3. List of all problems patient now faces
4. Based on problems what are plans to deal with problems
2 parts to Database
1. History (subjective)
2. Performance of Physical Exam (objective)
Performance of Physical Exam (objective)
- Inspection (may require instruments
- Palpation
- Percussion
- Auscultation
Abdominal Exam follows different order ... what is it?
- Inspection
- Auscultation
- Percussion
- Palpation
Assessment History and Physical Exam
How reliable are the symptoms?
Is it a significant departure from normal?
Try to localize.
What system? Cardiac, Musculoskeletal, Respiratory. Specific organ?
Construct hypotheses.
A list of all possibilities to explain findings. The more the better.
Give it a title = DDx = Differential Diagnosis
Rule out hypotheses that do not fit with knowledge and findings.
Types of Diagnosis
Preliminary Diagnosis
Tentative Diagnosis
Working Diagnosis
Provisional Diagnosis
Probable Diagnosis
Diagnostic Impression

Last hypothesis standing is the one that best fits

Final or Definitive Diagnosis
Only when lab finding confirms your diagnostic impression
Face Sheet content
- Date
- Patient Info (Name, Address, Sex, Age, Place of Birth, Ethnicity, Etc.)
- Informant – who is giving the info
Cachexia
Look thin, emaciated, sick
Thermoscan Temp.
Infrared shot against tympanic membrane
i. Use this to get REAL core temperature
ii. Same blood supply to tympanic membrane & hypothalamus
Rectal Temp.
- done on infants
- Always 1° F greater than if done orally
Axillary Temp.
- if all else fails
- Leave there for ~5 min
- 1° F lower than oral
Temp Diurnal Cycle
- Range of temps
- 1° - 1.5° F
- Peaks in later afternoon and early evening

- Increase with exercise

- Increase .5 – 1° F mid cycle to onset of menstruation due to increase in progesterone

- Older patients have lower temps
Temp Range
- Normal = 96.4 – 99.1° F
- After eating for ~20 min temp increases ~ .3° C
*Use of muscles of mastication

- Hot Drink ↑ .9°
- Ice Drink ↓
- Smoking ↑
- Tachnyea ↓
- Amount of serumen in the ear canal
- Paresis ↓ on side affected
Fever
- Patient is febrile (pyrexic)
- > 99.0° F Orally
- > 100.0° F Rectally
Reason for fever
1. Infection
2. Inflammation
- Toxemia
– Malignancy? Drug rxn?
- Stroke
Sustained Fever
-Fever level same day after day

ex. Lobar pneumonia
Intermittent Fever
- Up and down
Quotidan fever (intermittent)
intermittent on daily basis
Tertian fever (intermittent)
change every 48 hours

Malarial
Quartan fever (intermittent)
change every 72 hrs

Malarial
Remittent (Continuous) Fever
- Never comes back down to normal

- Typhoid Fever
Relapsing Fever
- Fever one day not the next
- Hodgkin’s disease, Pel Ebstein fever
- Rat bite
- Infection from borrelia
Hectic Fever
- Intermittent or remittent
- Very wide swings in temp
- TB
Symptoms common with Bacterial Infection fever
- High grade fever
- No constitutional symptoms
- Easily localize problem
ie. Sore throat finger from cut
Symptoms common with Viral Infection fever
- Low grade fever
- Constitutional symptoms
ie. Muscle aches, joint aches, malaise, fatigue
- Difficulty localizing sickness
Signs of febrile state
1. Low or High grade fever
2. Skin is warm to touch
3. Skin looks flushed
4. Pulse rates are always elevated
5. Rigors (Chills)
6. Night sweats
7. Possibility of Jaundice
Factitious Fever
FUO – Fever Unknown Origin
- Needs to be at least 3 weeks
- >101° F
- All labs negative

Atypical Presentation of something common

- Hidden tumor or hidden infection
Idiopathic Fever
- Bacterial infection most typically
- Over age 50
- Diabetic patient
- WBC > 15,000 (norm 5,000 – 10,000/mm3)
- Elevated Erythrocyte Sedimentation Rate (ESR)
- Infection usually in chest or urinary tract
Very High Fever
In general fevers are NEVER beneficial to host

1. Major metabolic demand on body
2. Reduced mental activity
3. Uncomfortable
Termination by Crisis
-Rapid termination of fever
Termination by Lysis
- Gradual termination of fever
Subnormal temp
< 95.0° F (35C)

Find out if temp is normal for patient or not

Due to chronic problems
-Hypothyroidism, Neoplasms
-Drugs – Barbiturates, Alcoholics
Acute Subnormal Temperature
Exposure, Trauma, Myocardial Infarction, Diabetic Coma, Peripheral Vascular Collapse, Drug Rxn, Anaphylactic Rxn
Pulse Evaluation (where?)
Radial Artery – Just medial to styloid process
Where on chest would you count heartbeats?
5th intercostals space, medial to left ventricular line
What is pulse deficit?
difference between radial and apical rates

- Apical is always slightly greater than radial
Palpate artery for 4 reasons
- Rate
- Rhythm
- Character/Quality/Contour
- Consistency of Artery
Heart rate norms (adult, children, athlete)
95% of healthy adult 50 – 95 bpm

Children 90 – 120 bpm

Well trained athlete ~ 50 bpm
Tachycardia
> 100 bpm
- Hyperkinetic State
-As fever increases so does pulse rate
-Anemia, Hyperthyroidism, Overly Anxious, Just exercised
.... Body has increased metabolic need
Bradycardia
< 50 bpm
- Patient passes out
- Obstructive Jaundice
- Increased Intracranial pressure
Rhythm
Distance between pulse beats

Normal sinus rhythm
Irregular rhythm
Arrythmia

- Should be diagnosed with EKG
Sinus Arrythmia
most common arrythmia

- Rate goes up and down
- Most common in people over 40 and children
- Faster during inspiration, slower during expiration
- No clinical significance
The “Pause”
2nd most common arrythmia

- Premature systoles
- Excessive drinking, smoking
- Overdosage of Digitalis – dosage is too strong
- Stress
Chaotic Rhythm
- Irregularly irregular pulse
- Radial and Apical – irregular and erratic
- Probably Atrial fibrillation or Atrial flutter
Character or Quality of pulse
- Dicrodic Notch – not palpable
- Normal contour smooth and round
Abnormal Pulses
Pulsus Magnus
Pulsus Parvus
Pulsus Bisferiens
Pulsus Alternans
Pulsus Differens
Labile Pulse
Pulsus Magnus
- AKA Corrigan Pulse
- Hyperkinetic Pulse
- Collapsing Pulse
- Large Bounding Pulse
- Water hammer Pulse
Hyperkinetic state
– patient is febrile, anemic, anxious
Hypertensive – High BP
Cardiac Pathology
- Patent Ductus Arteriosus
- Aortic Valve Regurgitation
- Aortic Atherosclerosis
Pulsus Parvus
- Small, Weak or Thready pulse
- Slow uptake, prolonged peak, long downsweep
Causes of Pulsus Parvus
Hypovolemia – dehydration

Cardiac Reasons
1. Aortic Stenosis
2. Mitral Stenosis
3. Left Ventricular failure
4. Constrictive Pericarditis
5. Cardiac tempnon
Pulsus Bisferiens
- Double beat pulse
- Rapid upstroke, rapid 2nd upstroke
Causes of Pulsus Bisferiens
Aortic valve is very wide and allows regurgitation, but is also stenotic
Pulsus Alternans
- Strong followed by weak, with normal rhythm
Causes of Pulsus Alternans
- Severe hypertension
- Left Ventricular failure
Pulsus Differens
- Pulse on right different then left or vice versa
- Rates are different not character
- Impairment on side of lower rate
Labile Pulse
- No significance
- Patient supine pulse rate is normal, pulse goes up when sitting or standing
Consistancy of Artery
- Soft and supple (pliable)
- Can we express blood out by squeezing
- No resistance
- Don’t want “Pipe stem rigidity” artery
Respiration (avg range)
16 – 25 breaths per minute
Respiration avg. (not range)
Avg. = 20 bpm
Tachypnea
>25 bpm

- With cough and fever is almost diagnostic of pneumonia
- Cardiac arrest patients show Tachypnea
Bradypnea
< 8 bpm

- Severe respiration depression
- Patient on Opiods, sedation
Dyspnea
Shortness of Breath (SOB)
Orthopnea
- Patient has tachypnea and dysnea while supine

- Relieved when patient sits up
Causes of orthpnea
1. Congestive heart failure!!!


2. Ascites (massive)
3. Bilateral diaphragmatic paralysis
4. Pleural diffusion (lots of fluid in pleura of lungs)
5. Severe pneumonia
Trepopnea
- Breathing difficulty is worse in one lateral cubitis position (lying on one’s side)

- Relieved if on back
Causes of Trepopnea
1. Unilateral disease of lung
2. Bronchial tumor
3. Cardial myopathy
Platypnea
- Dysnea is worse in supine position
- Does not get better when seated like orthopnea
Causes of platypnea
1. Right to left shunt pathologies
2. Patent foramen ovale
3. Interventricular valve subtle defect
4. Atrio-septal defect
Cheyne Stokes Respiration
- Diamond shaped preceded and followed by apnea
- Often when patient sleeps, normal in some
- Can be caused by a high altitude
Causes of Cheyne Stokes Respiration
1. Congestive heart failure < 30%
2. Hemorrhage in Brain
3. Infarction
4. Tumor
5. Meningitis
Kussmalls Respiration
- Hyperventilation – very rapid and deep breathing
- Most in response to metabolic acidosis
Biots Respiration
- irregular periods of apnea alternating with four or five deep breaths

- seen with increased intracranial pressure

(from Steadmans)
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