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Suggest Treatment For Edema In Ankles
Brief Answer:
I would need your input
Detailed Answer:
Hi,
Welcome to Health Care Magic.
I am Dr.Muhammad Ahmad, I have read your question in detail, I will try to help you in the best possibleway
Please tell me the purpose of your asking it, if you are a medical professional and up for and exam I will tell you in a sequence and in medical terms if you are not realted to medicine and asking for information then i will use simple langage to make you understand better about the topic under discussion.
Regards.
Dr.Muhammad Ahmad.
M.B.B.S ( Licensed Family practitioner)
Resident M.D.
I would need your input
Detailed Answer:
Hi,
Welcome to Health Care Magic.
I am Dr.Muhammad Ahmad, I have read your question in detail, I will try to help you in the best possibleway
Please tell me the purpose of your asking it, if you are a medical professional and up for and exam I will tell you in a sequence and in medical terms if you are not realted to medicine and asking for information then i will use simple langage to make you understand better about the topic under discussion.
Regards.
Dr.Muhammad Ahmad.
M.B.B.S ( Licensed Family practitioner)
Resident M.D.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
I am turning in a case study. I am in a family nurse practitioner training program. She said:
Perform a directed history and physical examination. You should write the questions you would ask during the history (remember all of the possible differentials) and what physical examination would be done. Then answer the post-encounter questions.
I just want to see if there are more questions that I should ask for review of systems? Or, if there are body systems in the physical that I need to delete.
This is what I have completed:
ROS:
General: Do you have shortness of breath at all times, or when you exert movement? Do you have any cold sweats? Do you have any weight changes, fatigue, weakness, or fever?
Skin: Do you have any rashes, lumps, sores, itching, dryness, and changes in color from pink, changes in hair or nails, changes in size or color of moles.
Gastrointestinal: Do you have any nausea? Do you have any trouble swallowing, heartburn, anorexia, changes in bowel movements, changes in stool or color, pain with defecation, rectal bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea, abdominal pain, food intolerance, excessive belching or passing of gas, jaundice, liver, gallbladder trouble, or hepatitis.
Peripheral Vascular: You mentioned that you have swelling in your ankles, and do you have any swelling in the legs or feet. Do you have any intermittent claudication, leg cramps, varicose veins, past clots in veins, swelling in calves, color change in fingertips or toes during cold weather, swelling with redness or tenderness.
Hematologic: Do you have any anemia, easy bruising or bleeding, past transfusions, transfusion reactions.
Respiratory: Dyspnea on exertion. Trouble walking ½ block to store and gets as walk farther. When was your last X-Ray? Do you have any pain with deep breathing, or cough, sputum, hemoptysis, dyspnea, wheezing, pleurisy, asthma, bronchitis, emphysema, pneumonia, and tuberculosis?
Further explanation, and re-phrasing of the questions in ROS may be necessary dependent upon the patient’s level of healthcare knowledge.
Physical:
General Survey/ Vital Signs:
What is your name? What is your date of birth? What is the year? Where are you now? Can you tell me what you see on the Snelling chart (line by line)? I know we mentioned this before, but to repeat what is your current pain level?
Inspected the patient’s visual acuity, level of consciousness (to person/place/time), and if the patient was in acute distress.
Visually inspected: proper hygiene, appropriate attire (ex. is appropriate to the season?), grooming, odors of the breath or body, general state of health, height, build, sexual development, how patient is sitting (ex. Tripod), if accessory muscles are used, posture, motor activity, gait, and level of alertness (normal (wakefulness, awareness) or abnormal (confusion, lethargy)) watching the patient’s facial expressions, and manner, reactions, and affect to things and people in the environment. Listen to the manner of patient speaking (is speaking affected by dyspnea?). Does the patient appear to have a form of pulmonary congestion?
Measured the patient’s oxygen saturation, height, weight, temperature, pulse, respirations, blood pressure, and visual acuity to determine if within normal limits:
• Used a Pulse Oximeter: measured that the pulse was greater than 92%.
• Measured the patient’s Height, Weight, and Temperature (oral), Pulse (left arm, brachial), apical pulse, and all pulses peripherally grading them (normal range would be 2+), Respirations (within limits of 16 to 20), Blood Pressure (assess if the BP is high/low; want to determine if the BP is High?)
Skin:
Inspected the skin noting signs of color (is the skin pale?), patterns of hair distribution, any edematous signs, any identifiable lesions or nevi, or petechiae.
Inspected the hand for any signs of clubbing or pitting.
Palpated the skin for texture, moisture, and assessed temperature (is the skin cool?). Assessed mobility/turgor (normal range would be skin is elastic and no sign of tenting).
Palpated the DIP and PIP for any bogginess or tenderness.
Palpated the nail bed checking for capillary refill (a normal sign would be the nail bed blanches and returns to pink within 3 seconds). Tested the range of motion of the fingers, wrist, and elbow.
Continued the skin assessment throughout examination of other body regions.
Neck:
Inspected the cervical lymph nodes for presence. Inspected that the trachea is midline. Inspected the sounds and effort of breathing (labored or unlabored). Inspected the thyroid gland,
Palpated the neck noting any unusual pulses or masses.
Palpated the thyroid gland looking for any enlargement, nodules, or tenderness.
Palpated the cervical lymph nodes (with a normal sign being the lymph nodes are less than 1cm, XXXXXXX and nontender). Palpated the trachea for any deviation.
Auscultation: tested whether the patient’s auscultated breathing is bronchial over the trachea and for bruits in thyroid.
Back, Posterior Thorax and Lungs:
Inspected the muscles of the upper back and spine, and shoulder height for symmetry. Inspected the back.
Assessed Tactile Fremitus.
Palpated the muscles of the upper back and spine, including the costovertebral angles. Palpated the back.
Percussed the back (where a normal sound is resonant). Identified the diaphragmatic excursion (where a normal limit is between 3-5 cm). Also, tapped the costovertebral angles for any signs of pain.
Auscultated the back listening for a normal finding of Bronchovesicular over the thoracic vertebra and vesicular over the lung fields, and for any adventitious breath sounds (if indicated, then listened to any transmitted voice sounds, ex. Egophony, with normal finding of No E to A transition). Listened for any adventitious inspiratory crackles at the base.
Supraclavicular, Infraclavicular, Pectoral, Subscapular, Deep Central, and Epitrochlear Lymph Nodes:
Assessed if they were palpable, XXXXXXX non-tender, and less than 1 cm.
Anterior Thorax and Lungs:
Inspected the anterior:transverse diameter (with a normal range is 1:2).
Assessed Tactile Fremitus (patient says 99 and should appear muffled).
Palpated the chest (looking for any abnormal masses).
Percussed the chest (with a normal finding of resonance).
Auscultation the chest, including the right middle lobe (for normal findings of vesicular over the lungs, and Bronchovesicular over the sternal border, and for any adventitious breath sounds (ex. Wheezes or crackles; and if indicated tested transmitted voice sounds, Egophony, for any E to A transitions).
Cardiovascular System:
Inspected the precordium looking for any lifts, heaves, or lumps.
Inspected the jugular venous pulsations and in relation to the sternal border measured the jugular venous distention.
Inspected the carotid pulsations.
Palpated for Thrills over the point of maximal impulse, aortic, Herb’s point, pulmonic, tricuspid, and mitral valve.
Palpated the carotid pulsations (assessing if bounding and if 2+). Palpated the point of maximal impulse.
Palpated the internal jugular venous pulse, and tested hepatojugular reflex distention (the internal jugular vein is elevated after the test).
Noted the location, diameter, duration, and amplitude of the apical impulse.
Auscultated with the bell and diaphragm over the Herbs point, aortic, pulmonic, tricuspid, and mitral valve (listening for physiologic splitting of the second heart sound, for the first and second heart sound, and any abnormal gallops, rubs, or murmurs; including S1 > S2 over the aortic and pulmonic valves; S1 = S2 at Herbs Point, and S2 > S1 over the tricuspid and mitral valve.
Auscultated over the carotid pulses with the bell listening for bruits.
Abdomen:
Inspected the abdomen (for any masses, bulges, or scars).
Palpated the abdomen (palpated lightly and then deeply), spleen, liver, kidneys (if palpable) and aorta (assessing pulsations).
Auscultated the abdomen (using the bell listening over the aorta, renal arteries, iliac arteries, femoral arteries; and using the diaphragm inspected bowel sounds (assessing hypoactive or hyperactive bowel sounds).
Percussed the abdomen (listening for tympani throughout), spleen, liver, and kidneys. Testing to see if sign of ascites, or abnormal masses.
Lower Extremities:
Inspected the legs and feet and assessing the edema on ankles (assessing if pitting/non-pitting and grading dent depth/rebound time 1+ to 4+). Inspected for any discoloration (ex., color is pale), ulcers, or varicose veins. Assessed lower extremity strength, bulk, tone; and also sensation and reflexes making note of any abnormal movements; assessed the range of motion of ankles, knees, and toes. Inspected the patient’s gait (and asked the patient if edema effects their ability to walk on heels, hop in place, and do shallow knee bends) and completed a Romberg test assessing Pronator drift. Inspected for any abnormal masses. Inspected for hernias.
Palpated the femoral pulses, popliteal pulses, and inguinal lymph nodes. Palpated for any abnormal masses.
Expected Findings:
Right Sided Congestive Heart Failure, R + L Congestive Sided Heart Failure (most likely), Thrombophlebitis; Chronic Venous Insufficiency
Body systems in the physical that I need to delete or add.*
I also want to note there are a couple errors in the physical assessment information above, but I am only concerned with verifying physical assessment systems that I should include/not include and the ROS and not the errors. Thank you for your assistance.
Finalizing submission. Please do not answer question. Time 1800.
Perform a directed history and physical examination. You should write the questions you would ask during the history (remember all of the possible differentials) and what physical examination would be done. Then answer the post-encounter questions.
I just want to see if there are more questions that I should ask for review of systems? Or, if there are body systems in the physical that I need to delete.
This is what I have completed:
ROS:
General: Do you have shortness of breath at all times, or when you exert movement? Do you have any cold sweats? Do you have any weight changes, fatigue, weakness, or fever?
Skin: Do you have any rashes, lumps, sores, itching, dryness, and changes in color from pink, changes in hair or nails, changes in size or color of moles.
Gastrointestinal: Do you have any nausea? Do you have any trouble swallowing, heartburn, anorexia, changes in bowel movements, changes in stool or color, pain with defecation, rectal bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea, abdominal pain, food intolerance, excessive belching or passing of gas, jaundice, liver, gallbladder trouble, or hepatitis.
Peripheral Vascular: You mentioned that you have swelling in your ankles, and do you have any swelling in the legs or feet. Do you have any intermittent claudication, leg cramps, varicose veins, past clots in veins, swelling in calves, color change in fingertips or toes during cold weather, swelling with redness or tenderness.
Hematologic: Do you have any anemia, easy bruising or bleeding, past transfusions, transfusion reactions.
Respiratory: Dyspnea on exertion. Trouble walking ½ block to store and gets as walk farther. When was your last X-Ray? Do you have any pain with deep breathing, or cough, sputum, hemoptysis, dyspnea, wheezing, pleurisy, asthma, bronchitis, emphysema, pneumonia, and tuberculosis?
Further explanation, and re-phrasing of the questions in ROS may be necessary dependent upon the patient’s level of healthcare knowledge.
Physical:
General Survey/ Vital Signs:
What is your name? What is your date of birth? What is the year? Where are you now? Can you tell me what you see on the Snelling chart (line by line)? I know we mentioned this before, but to repeat what is your current pain level?
Inspected the patient’s visual acuity, level of consciousness (to person/place/time), and if the patient was in acute distress.
Visually inspected: proper hygiene, appropriate attire (ex. is appropriate to the season?), grooming, odors of the breath or body, general state of health, height, build, sexual development, how patient is sitting (ex. Tripod), if accessory muscles are used, posture, motor activity, gait, and level of alertness (normal (wakefulness, awareness) or abnormal (confusion, lethargy)) watching the patient’s facial expressions, and manner, reactions, and affect to things and people in the environment. Listen to the manner of patient speaking (is speaking affected by dyspnea?). Does the patient appear to have a form of pulmonary congestion?
Measured the patient’s oxygen saturation, height, weight, temperature, pulse, respirations, blood pressure, and visual acuity to determine if within normal limits:
• Used a Pulse Oximeter: measured that the pulse was greater than 92%.
• Measured the patient’s Height, Weight, and Temperature (oral), Pulse (left arm, brachial), apical pulse, and all pulses peripherally grading them (normal range would be 2+), Respirations (within limits of 16 to 20), Blood Pressure (assess if the BP is high/low; want to determine if the BP is High?)
Skin:
Inspected the skin noting signs of color (is the skin pale?), patterns of hair distribution, any edematous signs, any identifiable lesions or nevi, or petechiae.
Inspected the hand for any signs of clubbing or pitting.
Palpated the skin for texture, moisture, and assessed temperature (is the skin cool?). Assessed mobility/turgor (normal range would be skin is elastic and no sign of tenting).
Palpated the DIP and PIP for any bogginess or tenderness.
Palpated the nail bed checking for capillary refill (a normal sign would be the nail bed blanches and returns to pink within 3 seconds). Tested the range of motion of the fingers, wrist, and elbow.
Continued the skin assessment throughout examination of other body regions.
Neck:
Inspected the cervical lymph nodes for presence. Inspected that the trachea is midline. Inspected the sounds and effort of breathing (labored or unlabored). Inspected the thyroid gland,
Palpated the neck noting any unusual pulses or masses.
Palpated the thyroid gland looking for any enlargement, nodules, or tenderness.
Palpated the cervical lymph nodes (with a normal sign being the lymph nodes are less than 1cm, XXXXXXX and nontender). Palpated the trachea for any deviation.
Auscultation: tested whether the patient’s auscultated breathing is bronchial over the trachea and for bruits in thyroid.
Back, Posterior Thorax and Lungs:
Inspected the muscles of the upper back and spine, and shoulder height for symmetry. Inspected the back.
Assessed Tactile Fremitus.
Palpated the muscles of the upper back and spine, including the costovertebral angles. Palpated the back.
Percussed the back (where a normal sound is resonant). Identified the diaphragmatic excursion (where a normal limit is between 3-5 cm). Also, tapped the costovertebral angles for any signs of pain.
Auscultated the back listening for a normal finding of Bronchovesicular over the thoracic vertebra and vesicular over the lung fields, and for any adventitious breath sounds (if indicated, then listened to any transmitted voice sounds, ex. Egophony, with normal finding of No E to A transition). Listened for any adventitious inspiratory crackles at the base.
Supraclavicular, Infraclavicular, Pectoral, Subscapular, Deep Central, and Epitrochlear Lymph Nodes:
Assessed if they were palpable, XXXXXXX non-tender, and less than 1 cm.
Anterior Thorax and Lungs:
Inspected the anterior:transverse diameter (with a normal range is 1:2).
Assessed Tactile Fremitus (patient says 99 and should appear muffled).
Palpated the chest (looking for any abnormal masses).
Percussed the chest (with a normal finding of resonance).
Auscultation the chest, including the right middle lobe (for normal findings of vesicular over the lungs, and Bronchovesicular over the sternal border, and for any adventitious breath sounds (ex. Wheezes or crackles; and if indicated tested transmitted voice sounds, Egophony, for any E to A transitions).
Cardiovascular System:
Inspected the precordium looking for any lifts, heaves, or lumps.
Inspected the jugular venous pulsations and in relation to the sternal border measured the jugular venous distention.
Inspected the carotid pulsations.
Palpated for Thrills over the point of maximal impulse, aortic, Herb’s point, pulmonic, tricuspid, and mitral valve.
Palpated the carotid pulsations (assessing if bounding and if 2+). Palpated the point of maximal impulse.
Palpated the internal jugular venous pulse, and tested hepatojugular reflex distention (the internal jugular vein is elevated after the test).
Noted the location, diameter, duration, and amplitude of the apical impulse.
Auscultated with the bell and diaphragm over the Herbs point, aortic, pulmonic, tricuspid, and mitral valve (listening for physiologic splitting of the second heart sound, for the first and second heart sound, and any abnormal gallops, rubs, or murmurs; including S1 > S2 over the aortic and pulmonic valves; S1 = S2 at Herbs Point, and S2 > S1 over the tricuspid and mitral valve.
Auscultated over the carotid pulses with the bell listening for bruits.
Abdomen:
Inspected the abdomen (for any masses, bulges, or scars).
Palpated the abdomen (palpated lightly and then deeply), spleen, liver, kidneys (if palpable) and aorta (assessing pulsations).
Auscultated the abdomen (using the bell listening over the aorta, renal arteries, iliac arteries, femoral arteries; and using the diaphragm inspected bowel sounds (assessing hypoactive or hyperactive bowel sounds).
Percussed the abdomen (listening for tympani throughout), spleen, liver, and kidneys. Testing to see if sign of ascites, or abnormal masses.
Lower Extremities:
Inspected the legs and feet and assessing the edema on ankles (assessing if pitting/non-pitting and grading dent depth/rebound time 1+ to 4+). Inspected for any discoloration (ex., color is pale), ulcers, or varicose veins. Assessed lower extremity strength, bulk, tone; and also sensation and reflexes making note of any abnormal movements; assessed the range of motion of ankles, knees, and toes. Inspected the patient’s gait (and asked the patient if edema effects their ability to walk on heels, hop in place, and do shallow knee bends) and completed a Romberg test assessing Pronator drift. Inspected for any abnormal masses. Inspected for hernias.
Palpated the femoral pulses, popliteal pulses, and inguinal lymph nodes. Palpated for any abnormal masses.
Expected Findings:
Right Sided Congestive Heart Failure, R + L Congestive Sided Heart Failure (most likely), Thrombophlebitis; Chronic Venous Insufficiency
Body systems in the physical that I need to delete or add.*
I also want to note there are a couple errors in the physical assessment information above, but I am only concerned with verifying physical assessment systems that I should include/not include and the ROS and not the errors. Thank you for your assistance.
Finalizing submission. Please do not answer question. Time 1800.
Brief Answer:
It was really well written few things could still be added
Detailed Answer:
Hello
I am sorry that you could not get this response at due time, I would suggest you to please add academic questions at-least with a margin of 24 hours so that they can be checked in detail with considered though and then answered in detail. Academic questions are different because we have to reply according to guidelines in a proper sequence, editing and adding things to a particular case history and examination takes times considering the differentials and everything. You finalized the assignment within three hours of your follow-up response which is not appropriate time for editing and well detailed reply. Always mention deadline in which you need an answer so that the picking doctor knows before answering if he can reply in time or not.We at HCM try not to answer health care related questions in a hurry we try to take our time to reply with best possible answer.
I am answering your question this will help you know how things will do in the case you mentioned. In a patient of COPD there is invariably pulmonary hypertension so this puts pressure on right ventricle, with time right ventricle starts to hypertrophy and right atrium gets the pressure in turn blood start polling in the veins which results in neck vein engorgement, abdominal vein engorgement liver and spleen engorgement, blood pools up in all these veins as heart is not taking the blood properly this results in edema in feet because there is much pressure in leg veins so fluid oozes out of them to cause edema in the feet.
So the systems expected to be involved would be , Lungs,heart,liver,spleen and peripheral veins.
ROS:
General: Do you have shortness of breath at all times, or when you exert movement?
>>>also ask about orthopnoea, if her breathlessness get worsened on lying down, this will tell you about left heart failure plus will differentiate between cause of dyspnea if it's due to COPD or cardiac failure<<<
Do you have any cold sweats? Do you have any weight changes, fatigue, weakness, or fever?
Skin: Do you have any rashes, lumps, sores, itching, dryness, and changes in color from pink, changes in hair or nails, changes in size or color of moles.
Gastrointestinal: Do you have any nausea? Do you have any trouble swallowing, heartburn, anorexia, changes in bowel movements, changes in stool or color, pain with defecation, rectal bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea, abdominal pain, food intolerance, excessive belching or passing of gas, jaundice, liver, gallbladder trouble, or hepatitis.
Peripheral Vascular: You mentioned that you have swelling in your ankles, and do you have any swelling in the legs or feet. Do you have any intermittent claudication, leg cramps, varicose veins, past clots in veins, swelling in calves, color change in fingertips or toes during cold weather, swelling with redness or tenderness.
Hematologic: Do you have any anemia, easy bruising or bleeding, past transfusions, transfusion reactions.
Respiratory: Dyspnea on exertion. Trouble walking ½ block to store and gets as walk farther. When was your last X-Ray? Do you have any pain with deep breathing, or cough, sputum, hemoptysis, dyspnea, wheezing, pleurisy, asthma, bronchitis, emphysema, pneumonia, and tuberculosis?
>>>>dyspnea on lying down which gets better sitting up signifies heart failure this you have to ask, ask about cyanosis, if dyspnea is seasonal , is there any allergen which causes it, <<<
Further explanation, and re-phrasing of the questions in ROS may be necessary dependent upon the patient’s level of healthcare knowledge.
Physical:
General Survey/ Vital Signs:
What is your name? What is your date of birth? What is the year? Where are you now? Can you tell me what you see on the Snelling chart (line by line)? I know we mentioned this before, but to repeat what is your current pain level?
Inspected the patient’s visual acuity, level of consciousness (to person/place/time), and if the patient was in acute distress.
Visually inspected: proper hygiene, appropriate attire (ex. is appropriate to the season?), grooming, odors of the breath or body, general state of health, height, build, sexual development, how patient is sitting (ex. Tripod), if accessory muscles are used, posture, motor activity, gait, and level of alertness (normal (wakefulness, awareness) or abnormal (confusion, lethargy)) watching the patient’s facial expressions, and manner, reactions, and affect to things and people in the environment. Listen to the manner of patient speaking (is speaking affected by dyspnea?). Does the patient appear to have a form of pulmonary congestion?
>>>Here as you are concerned with repiration and heart so you will see if patient is dyspneic, distressedm sweating, gasping for air, expanding nostrils to grab more air,cyanosis, evident increased breathing rate, using accessory muscles of respiration, evident neck veins, on oxygen or off oxygen<<<
Measured the patient’s oxygen saturation, height, weight, temperature, pulse, respirations, blood pressure, and visual acuity to determine if within normal limits:
• Used a Pulse Oximeter: measured that the pulse was greater than 92%.
>>>measure it with and without oxygen>>
, patterns of hair distribution, any edematous signs, any identifiable lesions or nevi, or petechiae.
Inspected the hand for any signs of clubbing or pitting.
Palpated the skin for texture, moisture, and assessed temperature (is the skin cool?). Assessed mobility/turgor (normal range would be skin is elastic and no sign of tenting).
Palpated the DIP and PIP for any bogginess or tenderness.
Palpated the nail bed checking for capillary refill (a normal sign would be the nail bed blanches and returns to pink within 3 seconds). Tested the range of motion of the fingers, wrist, and elbow
>>>Also checked for any nodes on fingers which may show artheritis or infective endocarditis<<
Continued the skin assessment throughout examination of other body regions.
Neck:
Inspected the cervical lymph nodes for presence. Inspected that the trachea is midline. Inspected the sounds and effort of breathing (labored or unlabored). Inspected the thyroid gland,
>>ispected neck for any draining sinus(sommon in tuberculosis<<
>>thyroid to be inspected during swallowing as well to rule out thyroglossal duct<<
Palpated the neck noting any unusual pulses or masses.
Palpated the thyroid gland looking for any enlargement, nodules, or tenderness.
>>> + Bruit/Thrill >
Assessed Tactile Fremitus.
Palpated the muscles of the upper back and spine, including the costovertebral angles. Palpated the back.
Percussed the back (where a normal sound is resonant). Identified the diaphragmatic excursion (where a normal limit is between 3-5 cm). Also, tapped the costovertebral angles for any signs of pain.
Auscultated the back listening for a normal finding of Bronchovesicular over the thoracic vertebra and vesicular over the lung fields, and for any adventitious breath sounds (if indicated, then listened to any transmitted voice sounds, ex. Egophony, with normal finding of No E to A transition). Listened for any adventitious inspiratory crackles at the base.
Supraclavicular, Infraclavicular, Pectoral, Subscapular, Deep Central, and Epitrochlear Lymph Nodes:
Assessed if they were palpable, XXXXXXX non-tender, and less than 1 cm.
Anterior Thorax and Lungs:
Inspected the anterior:transverse diameter (with a normal range is 1:2).
>>>Inspect chest symmetry, equal chest expansion at both sides, intercostal recessions<<<
Assessed Tactile Fremitus (patient says 99 and should appear muffled).
Palpated the chest (looking for any abnormal masses).
Percussed the chest (with a normal finding of resonance).
Auscultation the chest, including the right middle lobe (for normal findings of vesicular over the lungs, and Bronchovesicular over the sternal border, and for any adventitious breath sounds (ex. Wheezes or crackles; and if indicated tested transmitted voice sounds, Egophony, for any E to A transitions).
>>Meassure chest expansion with measuing tape<<
Cardiovascular System:
Inspected the precordium looking for any lifts, heaves, or lumps.
Inspected the jugular venous pulsations and in relation to the sternal border measured the jugular venous distention.
Inspected the carotid pulsations.
>>Inspect any visible veins<<
Palpated for Thrills over the point of maximal impulse, aortic, Herb’s point, pulmonic, tricuspid, and mitral valve.
Palpated the carotid pulsations (assessing if bounding and if 2+).
>>>Check carotid thrill<<
Palpated the point of maximal impulse.
Palpated the internal jugular venous pulse, and tested hepatojugular reflex distention (the internal jugular vein is elevated after the test).
Noted the location, diameter, duration, and amplitude of the apical impulse.
Auscultated with the bell and diaphragm over the Herbs point, aortic, pulmonic, tricuspid, and mitral valve (listening for physiologic splitting of the second heart sound, for the first and second heart sound, and any abnormal gallops, rubs, or murmurs; including S1 > S2 over the aortic and pulmonic valves; S1 = S2 at Herbs Point, and S2 > S1 over the tricuspid and mitral valve.
Auscultated over the carotid pulses with the bell listening for bruits.
Abdomen:
Inspected the abdomen (for any masses, bulges, or scars>>>spider navi, caput maddusae<<<
Palpated the abdomen (palpated lightly and then deeply), spleen, liver, kidneys (if palpable) and aorta (assessing pulsations).
Auscultated the abdomen (using the bell listening over the aorta, renal arteries, iliac arteries, femoral arteries; and using the diaphragm inspected bowel sounds (assessing hypoactive or hyperactive bowel sounds).
Percussed the abdomen (listening for tympani throughout
>>>dull over liver<<<)
, spleen, liver, and kidneys. Testing to see if sign of ascites, or abnormal masses.
Lower Extremities:
Inspected the legs and feet and assessing the edema on ankles (assessing if pitting/non-pitting and grading dent depth/rebound time 1+ to 4+). Inspected for any discoloration (ex., color is pale), ulcers, or varicose veins. Assessed lower extremity strength, bulk, tone>>>compared both limbs<<
>>Also check for calf tendetness it can be present in settings of DVT which is common in heart and liver issues<<
; and also sensation and reflexes making note of any abnormal movements; assessed the range of motion of ankles, knees, and toes. Inspected the patient’s gait (and asked the patient if edema effects their ability to walk on heels, hop in place, and do shallow knee bends) and completed a Romberg test assessing Pronator drift. Inspected for any abnormal masses. Inspected for hernias.
Palpated the femoral pulses, popliteal pulses, and inguinal lymph nodes. Palpated for any abnormal masses.
Expected Findings:
Right Sided Congestive Heart Failure, R + L Congestive Sided Heart Failure (most likely), Thrombophlebitis; Chronic Venous Insufficiency
>>> + enlarged or shrunken liver depending upon severity of congestion..enlarged spleen<<<
Regards
Dr.Muhammad Ahmad
It was really well written few things could still be added
Detailed Answer:
Hello
I am sorry that you could not get this response at due time, I would suggest you to please add academic questions at-least with a margin of 24 hours so that they can be checked in detail with considered though and then answered in detail. Academic questions are different because we have to reply according to guidelines in a proper sequence, editing and adding things to a particular case history and examination takes times considering the differentials and everything. You finalized the assignment within three hours of your follow-up response which is not appropriate time for editing and well detailed reply. Always mention deadline in which you need an answer so that the picking doctor knows before answering if he can reply in time or not.We at HCM try not to answer health care related questions in a hurry we try to take our time to reply with best possible answer.
I am answering your question this will help you know how things will do in the case you mentioned. In a patient of COPD there is invariably pulmonary hypertension so this puts pressure on right ventricle, with time right ventricle starts to hypertrophy and right atrium gets the pressure in turn blood start polling in the veins which results in neck vein engorgement, abdominal vein engorgement liver and spleen engorgement, blood pools up in all these veins as heart is not taking the blood properly this results in edema in feet because there is much pressure in leg veins so fluid oozes out of them to cause edema in the feet.
So the systems expected to be involved would be , Lungs,heart,liver,spleen and peripheral veins.
ROS:
General: Do you have shortness of breath at all times, or when you exert movement?
>>>also ask about orthopnoea, if her breathlessness get worsened on lying down, this will tell you about left heart failure plus will differentiate between cause of dyspnea if it's due to COPD or cardiac failure<<<
Do you have any cold sweats? Do you have any weight changes, fatigue, weakness, or fever?
Skin: Do you have any rashes, lumps, sores, itching, dryness, and changes in color from pink, changes in hair or nails, changes in size or color of moles.
Gastrointestinal: Do you have any nausea? Do you have any trouble swallowing, heartburn, anorexia, changes in bowel movements, changes in stool or color, pain with defecation, rectal bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea, abdominal pain, food intolerance, excessive belching or passing of gas, jaundice, liver, gallbladder trouble, or hepatitis.
Peripheral Vascular: You mentioned that you have swelling in your ankles, and do you have any swelling in the legs or feet. Do you have any intermittent claudication, leg cramps, varicose veins, past clots in veins, swelling in calves, color change in fingertips or toes during cold weather, swelling with redness or tenderness.
Hematologic: Do you have any anemia, easy bruising or bleeding, past transfusions, transfusion reactions.
Respiratory: Dyspnea on exertion. Trouble walking ½ block to store and gets as walk farther. When was your last X-Ray? Do you have any pain with deep breathing, or cough, sputum, hemoptysis, dyspnea, wheezing, pleurisy, asthma, bronchitis, emphysema, pneumonia, and tuberculosis?
>>>>dyspnea on lying down which gets better sitting up signifies heart failure this you have to ask, ask about cyanosis, if dyspnea is seasonal , is there any allergen which causes it, <<<
Further explanation, and re-phrasing of the questions in ROS may be necessary dependent upon the patient’s level of healthcare knowledge.
Physical:
General Survey/ Vital Signs:
What is your name? What is your date of birth? What is the year? Where are you now? Can you tell me what you see on the Snelling chart (line by line)? I know we mentioned this before, but to repeat what is your current pain level?
Inspected the patient’s visual acuity, level of consciousness (to person/place/time), and if the patient was in acute distress.
Visually inspected: proper hygiene, appropriate attire (ex. is appropriate to the season?), grooming, odors of the breath or body, general state of health, height, build, sexual development, how patient is sitting (ex. Tripod), if accessory muscles are used, posture, motor activity, gait, and level of alertness (normal (wakefulness, awareness) or abnormal (confusion, lethargy)) watching the patient’s facial expressions, and manner, reactions, and affect to things and people in the environment. Listen to the manner of patient speaking (is speaking affected by dyspnea?). Does the patient appear to have a form of pulmonary congestion?
>>>Here as you are concerned with repiration and heart so you will see if patient is dyspneic, distressedm sweating, gasping for air, expanding nostrils to grab more air,cyanosis, evident increased breathing rate, using accessory muscles of respiration, evident neck veins, on oxygen or off oxygen<<<
Measured the patient’s oxygen saturation, height, weight, temperature, pulse, respirations, blood pressure, and visual acuity to determine if within normal limits:
• Used a Pulse Oximeter: measured that the pulse was greater than 92%.
>>>measure it with and without oxygen>>
, patterns of hair distribution, any edematous signs, any identifiable lesions or nevi, or petechiae.
Inspected the hand for any signs of clubbing or pitting.
Palpated the skin for texture, moisture, and assessed temperature (is the skin cool?). Assessed mobility/turgor (normal range would be skin is elastic and no sign of tenting).
Palpated the DIP and PIP for any bogginess or tenderness.
Palpated the nail bed checking for capillary refill (a normal sign would be the nail bed blanches and returns to pink within 3 seconds). Tested the range of motion of the fingers, wrist, and elbow
>>>Also checked for any nodes on fingers which may show artheritis or infective endocarditis<<
Continued the skin assessment throughout examination of other body regions.
Neck:
Inspected the cervical lymph nodes for presence. Inspected that the trachea is midline. Inspected the sounds and effort of breathing (labored or unlabored). Inspected the thyroid gland,
>>ispected neck for any draining sinus(sommon in tuberculosis<<
>>thyroid to be inspected during swallowing as well to rule out thyroglossal duct<<
Palpated the neck noting any unusual pulses or masses.
Palpated the thyroid gland looking for any enlargement, nodules, or tenderness.
>>> + Bruit/Thrill >
Assessed Tactile Fremitus.
Palpated the muscles of the upper back and spine, including the costovertebral angles. Palpated the back.
Percussed the back (where a normal sound is resonant). Identified the diaphragmatic excursion (where a normal limit is between 3-5 cm). Also, tapped the costovertebral angles for any signs of pain.
Auscultated the back listening for a normal finding of Bronchovesicular over the thoracic vertebra and vesicular over the lung fields, and for any adventitious breath sounds (if indicated, then listened to any transmitted voice sounds, ex. Egophony, with normal finding of No E to A transition). Listened for any adventitious inspiratory crackles at the base.
Supraclavicular, Infraclavicular, Pectoral, Subscapular, Deep Central, and Epitrochlear Lymph Nodes:
Assessed if they were palpable, XXXXXXX non-tender, and less than 1 cm.
Anterior Thorax and Lungs:
Inspected the anterior:transverse diameter (with a normal range is 1:2).
>>>Inspect chest symmetry, equal chest expansion at both sides, intercostal recessions<<<
Assessed Tactile Fremitus (patient says 99 and should appear muffled).
Palpated the chest (looking for any abnormal masses).
Percussed the chest (with a normal finding of resonance).
Auscultation the chest, including the right middle lobe (for normal findings of vesicular over the lungs, and Bronchovesicular over the sternal border, and for any adventitious breath sounds (ex. Wheezes or crackles; and if indicated tested transmitted voice sounds, Egophony, for any E to A transitions).
>>Meassure chest expansion with measuing tape<<
Cardiovascular System:
Inspected the precordium looking for any lifts, heaves, or lumps.
Inspected the jugular venous pulsations and in relation to the sternal border measured the jugular venous distention.
Inspected the carotid pulsations.
>>Inspect any visible veins<<
Palpated for Thrills over the point of maximal impulse, aortic, Herb’s point, pulmonic, tricuspid, and mitral valve.
Palpated the carotid pulsations (assessing if bounding and if 2+).
>>>Check carotid thrill<<
Palpated the point of maximal impulse.
Palpated the internal jugular venous pulse, and tested hepatojugular reflex distention (the internal jugular vein is elevated after the test).
Noted the location, diameter, duration, and amplitude of the apical impulse.
Auscultated with the bell and diaphragm over the Herbs point, aortic, pulmonic, tricuspid, and mitral valve (listening for physiologic splitting of the second heart sound, for the first and second heart sound, and any abnormal gallops, rubs, or murmurs; including S1 > S2 over the aortic and pulmonic valves; S1 = S2 at Herbs Point, and S2 > S1 over the tricuspid and mitral valve.
Auscultated over the carotid pulses with the bell listening for bruits.
Abdomen:
Inspected the abdomen (for any masses, bulges, or scars>>>spider navi, caput maddusae<<<
Palpated the abdomen (palpated lightly and then deeply), spleen, liver, kidneys (if palpable) and aorta (assessing pulsations).
Auscultated the abdomen (using the bell listening over the aorta, renal arteries, iliac arteries, femoral arteries; and using the diaphragm inspected bowel sounds (assessing hypoactive or hyperactive bowel sounds).
Percussed the abdomen (listening for tympani throughout
>>>dull over liver<<<)
, spleen, liver, and kidneys. Testing to see if sign of ascites, or abnormal masses.
Lower Extremities:
Inspected the legs and feet and assessing the edema on ankles (assessing if pitting/non-pitting and grading dent depth/rebound time 1+ to 4+). Inspected for any discoloration (ex., color is pale), ulcers, or varicose veins. Assessed lower extremity strength, bulk, tone>>>compared both limbs<<
>>Also check for calf tendetness it can be present in settings of DVT which is common in heart and liver issues<<
; and also sensation and reflexes making note of any abnormal movements; assessed the range of motion of ankles, knees, and toes. Inspected the patient’s gait (and asked the patient if edema effects their ability to walk on heels, hop in place, and do shallow knee bends) and completed a Romberg test assessing Pronator drift. Inspected for any abnormal masses. Inspected for hernias.
Palpated the femoral pulses, popliteal pulses, and inguinal lymph nodes. Palpated for any abnormal masses.
Expected Findings:
Right Sided Congestive Heart Failure, R + L Congestive Sided Heart Failure (most likely), Thrombophlebitis; Chronic Venous Insufficiency
>>> + enlarged or shrunken liver depending upon severity of congestion..enlarged spleen<<<
Regards
Dr.Muhammad Ahmad
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
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