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NotesClinical Medicine Pocket Guide Bruce Y. Lee, MD, MBA Purchase additional copies of this book at your health science bookstore or directly from F.A. Davis by shopping online at www.fadavis.com or by calling 800-323- 3555 (US) or 800-665-1148 (CAN) A Davis’s Notes Book F.A. DAVIS COMPANY ‱ Philadelphia Medical Notes FADevisM_FM.qxp 9/12/08 7:46 PM Page 3
F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2009 by F. A. Davis Company All rights reserved. This product is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without writ- ten permission from the publisher. Printed in China by Imago Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Acquisitions Editor: Andy McPhee Developmental Editor: Yvonne Gillam Manager of Art and Design: Carolyn O’Brien Reviewers: Julie Z. Belcher, MD; Anna M. Choo, MD, JD; Carlos Duarte, MD; Brian G. Dwinnell, MD; Adam D. Elkin, MD; Sam Ghaffari, DO; Shilpa Grover, MD; Naghmeh Khodai, MD; Leslie H. Lee, MD; Elizabeth Mack, MD; John Tobias Musser, MD; Diane E. Nuñez, MS, ANP-C; Manali Indravadan Patel, MD, MPH; Mohammad Qasaymeh, MD; Susan D. Wolfsthal, MD; Erica Young, PA; and Kevan M. Zipin, MD As new scientiïŹc information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Authorization to photocopy items for internal or personal use, or the internal or per- sonal use of speciïŹc clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, pro- vided that the fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Dan- vers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-1746/09 Ï© $.25. FADevisM_FM.qxp 9/12/08 7:46 PM Page 4
Place 27 ⁄8 Ï« 27 ⁄8 Sticky Notes here for a convenient and reïŹllable pad ✓ HIPAA Compliant ✓ OSHA Compliant Waterproof and Reusable Wipe-Free Pages Write directly onto any page of MD Notes with a ballpoint pen. Wipe old entries off with an alcohol pad and reuse. FADevisM_FM.qxp 9/12/08 7:46 PM Page 5
Look for our other Davis’s Notes titles Coding Notes: Medical Insurance Pocket Guide ISBN-10: 0-8036-1536-1 / ISBN-13: 978-0-8036-1536-6 Derm Notes: Dermatology Clinical Pocket Guide ISBN-10: 0-8036-1495-0 / ISBN-13: 978-0-8036-1495-6 ECG Notes: Interpretation and Management Guide ISBN-10: 0-8036-1347-4 / ISBN-13: 978-0-8036-1347-8 LabNotes: Guide to Lab and Diagnostic Tests ISBN-10: 0-8036-1265-6 / ISBN-13: 978-0-8036-1265-5 NutriNotes: Nutrition & Diet Therapy Pocket Guide ISBN-10: 0-8036-1114-5 / ISBN-13: 978-0-8036-1114-6 MA Notes: Medical Assistant’s Pocket Guide ISBN-10: 0-8036-1281-8 / ISBN-13: 978-0-8036-1281-5 Neuro Notes: Clinical Pocket Guide ISBN-10: 0-8036-1747-X / ISBN-13: 978-0-8036-1747-6 Ortho Notes: Clinical Examination Pocket Guide ISBN-10: 0-8036-1350-4 / ISBN-13: 978-0-8036-1350-8 Provider’s Coding Notes: Billing & Coding Pocket Guide ISBN-10: 0-8036-1745-3 / ISBN-13: 978-0-8036-1745-2 PsychNotes: Clinical Pocket Guide ISBN-10: 0-8036-1286-9 / ISBN-13: 978-0-8036-1286-0 Rehab Notes: Evaluation and Intervention Pocket Guide ISBN-10: 0-8036-1398-9 /ISBN-13: 978-0-8036-1398-0 Respiratory Notes: Respiratory Therapist’s Guide ISBN-10: 0-8036-1467-5 / ISBN-13: 978-0-8036-1467-3 Screening Notes: Rehabilitation Specialists Pocket Guide ISBN-10: 0-8036-1573-6 /ISBN-13: 978-0-8036-1573-1 For a complete list of Davis’s Notes and other titles for health care providers, visit www.fadavis.com FADevisM_FM.qxp 9/12/08 7:46 PM Page 6
Diseases and Disorders American Cancer Society Guidelines: Cancer (CA) Detection Breast CA (Women) ■ Ն40 y.o.: Mammogram every year ■ Clinical breast exam: 20-39 y.o. ~q3yr and Ն40 y.o. every year ■ Breast self-exam option for Ն20 y.o ■ ÏŸ20% lifetime risk: MRI and mammogram every year ■ 15%-20% lifetime risk: discuss w/physician about MRI Colon and Rectal CA ■ Ն50 y.o. male or female: Do one of following ïŹve: ■ Fecal occult blood test (FOBT) or fecal immunochemical test (FIT) every year ■ Flexible sigmoidoscopy q5yr ■ Yearly FOBT or FIT and ïŹ‚exible sigmoidoscopy q5yr (preferred) ■ Double-contrast barium enema q5yr ■ Colonoscopy q10yr ■ Start earlier (e.g., Ն40 y.o.) if: ■ Pt history of colorectal CA, adenomatous polyps, or chronic inïŹ‚ammatory bowel disease ■ Strong family history of colorectal CA or polyps (CA or polyps ïŹrst-degree relative Ïœ60 y.o. or two ïŹrst-degree relatives any age) ■ Family history of hereditary colorectal CA syndrome Cervical CA (for Women) ■ ~3 yr after begin vaginal intercourse or Ն21 y.o., whichever comes ïŹrst: Regular Papanicolaou (Pap) test every year or newer liquid-based Pap test q2yr ■ When Ն30 y.o.: ■ May continue every year or change to q3yr HPV DNA test and either conventional or liquid-based Pap test ■ If 3 normal Pap tests in a row, may change to q2-3yr ■ If risk factors*: Continue every year 1 BASICSBASICS *Prenatal DES exposure, HIV, or Ăžimmunity FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 1
■ Ն70 y.o.: If Ն3 normal Pap tests in row and no abnormal Pap last 10 years, may stop; if risk factors,* continue every year ■ Total hysterectomy (uterus and cervix): May stop, unless surgery was for cervical CA or pre-CA Endometrial (Uterine) CA (for Women) ■ High risk for hereditary nonpolyposis colon CA: Ն35 y.o.: offer endometrial biopsy every year Prostate CA (for Men) ■ Ն50 y.o.: Offer prostate-speciïŹc antigen and digital rectal examination every year ■ Ն45 y.o. high-risk (African-American or strong family history Ն1 ïŹrst-degree relatives [father, brothers] diagnosis Ïœ65 y.o.): Every year ■ Ն40 y.o. higher risk (multiple ïŹrst-degree relatives): Every year; if negative consider waiting until Ն45 y.o. Diagnostic and Therapuetic Procedures Electrocardiogram (ECG) Rate (Normal: 60–100 bpm) ■ Bradycardia: Ïœ60 bpm; tachycardia: ÏŸ100 bpm P Waves ■ Normal: P upright (positive), uniform, precedes each ORS ■ None: Rhythm junctional or ventricular ■ Right atrial enlargement (RAE): P ÏŸ2.5 mm tall in II and/or ÏŸ1.5 mm in V1; better criteria: (RVH or RV displacement signs) QR, Qr, qR, or qRs in V1 (w/o CAD); QRS in V1 Ïœ5 mm and ratio V2/V1 voltage ÏŸ6 ■ Left atrial enlargement (LAE): P duration ÏŸ0.12 sec in II; notched P in limb leads w/interpeak duration ÏŸ0.04 sec; terminal P negativity in V1 duration ÏŸ0.04 sec, depth ÏŸ1 mm ■ Biatrial enlargement (BAE): RAE and LAE, P in II ÏŸ2.5 mm tall and ÏŸ0.12 sec duration; initial and component of P in V1 ÏŸ1.5 mm tall and prominent P-terminal force 2 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 2
PR Interval (Normal: 0.12–0.20 sec) ■ Short PR (Ïœ0.12 sec) Could be normal variant or: ■ Wolff-Parkinson-White (WPW): Accessory path RA†RV or LA†LV so early ventricle activation leads to Δ-wave (initial slurring of QRS), ⁄QRS duration (usu. ÏŸ0.10 sec), second- degree ST-T Δs from altered ventricular activation ■ Lown-Ganong-Levine: AV nodal bypass track into bundle of His † early ventricle activation w/o Δ-wave ■ AV junctional rhythms w/retrograde atrial activation (inverted P in II, III, aVF) ■ Ectopic atrial rhythms w/origin near AV node ■ Prolonged PR (:0.20 sec): ■ First-degree AV block (PR interval usu. constant); Ăžconduc- tion in atria, AV node, bundle of His, or bundle branch (when contralateral bundle blocked) ■ Second-degree AV block (PR interval normal or ⁄; some P waves do not conduct): Type I (Wenckebach): increasingly ⁄PR until a P not conducted; type II (Mobitz): ïŹxed PR intervals and nonconducted Ps ■ AV dissociation (Ps and QRS dissociated): Incomplete (slow SA node so subsidiary escape pacemaker takes over or subsidiary pacemaker faster than sinus rhythm) or complete (third-degree AV block: atria and ventricles each have separate pacemakers) QRS Complex ■ Poor R wave progression (PRWP): RՅ3 mm in V1–3, normal variant, LVH, LBBB, LAFB, anterior or anteroseptal MI, COPD (R/S ratio in V5–6 Ïœ1) ), diffuse inïŹltrative/myopathic processes, WPW pre-excitation, heart rotates clockwise, misplaced leads ■ Prominent anterior forces: R/S ratio ÏŸ1 in V1 or V2; normal variant, posterior MI, RBBB, WPW pre-excite QRS Interval (Normal: 0.6–0.10 sec) ■ QRS duration 0.10–0.12 sec: Incomplete RBBB or LBBB (same as complete RBBB and LBBB except QRS duration), nonspeciïŹc IVCD, LAFB, or LPFB (some) 3 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 3
■ QRS duration ÏŸ0.12 sec: ■ Complete RBBB: RV depolarizes after LV, second half QRS oriented right and anterior † terminal R’ in V1, terminal R in aVR, and downward ST-T in both V1/aVR; terminal S and upward ST-T in I, aVL, V6 ■ Complete LBBB: LV depolarizes after RV, second half QRS oriented left and posterior † terminal S and upward ST-T in V1; terminal R and downward ST-T in I, aVL, V6 ■ NonspeciïŹc Intraventricular Conduction DeïŹcit (IVCD): QRS duration ÏŸ0.10 sec but not bundle branch or fascicu- lar block criteria; causes: ventricular hypertrophy, MI, drugs (esp. class IA and IC antiarrhythmics), ⁄K+ ■ Ventricle-origin ectopic rhythm (e.g., VT) QT Interval (Normal: Ïœ1 ⁄2 R-R interval; normal QT Ïœ500 msec) ■ Beginning R wave † end of T wave; varies w/HR ■ Bazett’s formula: QTc = QT/͙RR (normal QTcՅ440 msec) ■ QTc ÏŸ0.47 sec (male) and ÏŸ0.48 sec (female) † long QT syn- drome (LQTS): (May † torsade de pointes: ventricular tachy- cardia w/varying QRS morphology): Drugs (e.g.,antiarrhyth- mics, tricyclics, phenothiazines); abnormal electrolytes (KÏ© , Ca2Ï© , Mg2Ï© ); Ăžthyroid, hypothermia, CNS dz (esp. SAH, CVA, trauma); hereditary LQTS; CAD (post-MI) Axis Deviation ■ Left-axis deviation (LAD): ■ LAFB: rS complexes in II, III, aVF; small Qs in I and/or aVL; R-peak time in aVL ÏŸ0.04 sec, often lurred R downstroke; QRS duration usu. Ïœ0.12 sec unless coexisting RBBB, usu. see poor R progression in V1–V3 and deeper S in V5 and V6, may mimic LVH voltage in aVL and mask LVH voltage in V5 and V6 ■ Other causes: LBBB, LVH, inferior MI, ⁄diaphragm ■ Right axis deviation (RAD): ■ LPFB: rS complex in lead I; qR in II, III, aVF, with R in III ÏŸR in II; QRS duration usu. Ïœ0.12 sec unless RBBB ■ Other causes: Cor pulmonale, pulmonary heart disease, pulmonary hypertension 4 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 4
ST Segment ■ ST elevation ■ Normal variant “early repolarization” (usu. concave up, ending w/symmetrical, large, upright T waves) ■ Ischemic heart disease: Acute transmural injury (usu. convex up or straightened); persistent in post-acute MI suggests ventricular aneurysm ■ Prinzmetal’s (variant) angina (coronary vasospasm) ■ During exercise testing †⁄⁄⁄tight coronary artery stenosis or spasm (transmural ischemia) ■ Acute pericarditis: Concave up ⁄ST (not aVR); no reciprocal ĂžST (except in aVR); unlike “early repolarization”, usu. T low amplitude and ⁄HR; may see ĂžPR (atrial injury) ■ Other causes: LVH (in right precordial leads w/large S); LBBB; ⁄K+ ; hypothermia ■ ST Depression ■ Normal variants/artifacts: Pseudo ST depression (poor skin-electrode contact); physiologic J-junctional depression w/sinus tachycardia; hyperventilation ■ Ischemic heart disease: Subendocardial ischemia, non Q-wave MI, reciprocal Δs in acute Q-wave MI (e.g., ST depression in leads I and aVL with acute inferior MI) ■ Nonischemic causes: RVH (right precordial leads) or LVH (left precordial leads, I, aVL), digoxin, ĂžK+ , MVP (some), CNS dz, second-degree to IVCD (e.g., WPW, BBB) T Wave ■ Normal: T same direction as QRS except in V2; asymmetric w/ïŹrst half moving more slowly than second half; T always upright in I, II, V3–6, and always inverted in aVR ■ T-wave inversions: Normal variant, myocardial ischemia or infarction or contusion, pericarditis (subacute or old), myocarditis, CNS dz †⁄QT (esp. SAH), idiopathic apical hypertrophy, MVP, abnormal electrolytes, O2, CO2, pH, or temperature, digoxin, post-tachycardia or -pacing, RVH and LVH w/”strain” 5 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 5
U Waves (Normal: Same Polarity and Usually Ïœ1/3 Amplitude of T) ■ Normal: Asymmetric w/ascending limb move more rapidly than descending limb (opposite to normal T) ■ Prominent upright U: Sinus bradycardia, ĂžKÏ© , Quinidine and other type 1A antiarrhythmics, CNS dz (long QT), LVH, MVP, Ăžthyroid ■ Negative or “inverted” U: Ischemic heart dz, MI (in leads with pathologic Q waves), angina, coronary vasospasm (Prinzmetal’s angina) ■ Nonischemic causes: Some cases of LVH or RVH (usu. in leads with prominent R waves), LQTS Myocardial Infarction ■ Q-wave MI: Total coronary occlusion ■ Non Q-wave MI: Subtotal occlusion ■ More leads with MI changes (Q waves and ST elevation) † larger infarct size and worse prognosis 6 BASICSBASICS Evolution of Q-Wave MI Q* T ST Pre-MI Hyperacute ⁄Amplitude/width May ⁄ Transmural Injury ⁄⁄⁄ Necrosis Ï© Terminal inversion Less Necrosis/Fibrosis Ï© Inversion Fibrosis Ï© Upright *Pathologic: duration ÏŸ0.04 s or ÏŸ25% R-amplitude ■ Conditions resembling MI: WPW pre-excitation (negative Δ-wave ~ pathologic Qs); IHSS (mimic pathologic Qs); LVH (QS or PRWP in V1-3); RVH (tall R in V1 or V2); LBBB (QS or PRWP in V1-3); pneumothorax (no right precordial R); COPD/cor pulmonale (no R V1-3 and/or inferior Q and RAD); LAFB (Qs anterior chest leads); acute pericarditis (⁄ST); CNS dz (diffuse ST-T wave Δs) FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 6
Atrial Arrythmias ■ Premature atrial complexes: Single or repetitive, unifocal or multifocal, ectopic P (P’) may hide in preceding ST-T; P’R interval nl/⁄; P’ may be nonconducted, conducted w/aberration (e.g., wide QRS), or conducted normal ■ Premature junctional complexes: Retrograde P appears before (PR usu. Ïœ0.12 sec), during, or after QRS ■ Atrial ïŹbrillation: Poorly deïŹned atrial activity; appearance may ~old saw; ventricular response = irregularly irregular unless AV block ■ Atrial ïŹ‚utter: Regular atrial activity w/”clean” sawtooth appear- ance in II, III, aVF, and usu. discrete ‘P’ in V1; atrial rate = 150- 450/min; AV conduction ratio may vary 2:1, 3:1, etc ■ Ectopic atrial tachycardia and rhythm: Ectopic, discrete, unifocal P’ w/atrial rate Ïœ250/min (Ïœ100 † rhythm); ectopic P' waves usu. precede QRS w/P'R interval ÏœRP' interval; ventricular response: 1:1 or varying AV block ■ Multifocal atrial tachycardia and rhythm: ՆThree different P morphologies in given lead; rate = 100-250/min (Ïœ100 † rhythm), varying P'R intervals; ventricles: irregularly irregular (i.e., often confused with atrial ïŹbrillation); may be intermittent ■ Paroxysmal supraventricular tachycardia: Different re-entry cicuits; sudden onset and stop; usu. narrow QRS (unless BBB or rate-related aberrant ventricular conduction); types: AV nodal re-entrant tachycardia, AV reciprocating tachycardia, sinoatrial re-entrant tachycardia ■ Junctional rhythms and tachycardias: ■ Junctional escape beats: Origin AV jxn; rate: 40-60 bpm ■ Junctional escape rhythm: Ն3 Junctional escapes; rate 40-60 bpm; may be AV dissociation or retrograde † atria ■ Accelerated junctional rhythm: Rate = 60-100 bpm ■ Nonparoxysmal junctional tachycardia: HR ÏŸ100 bpm Ventricular Arrythmias ■ Premature ventricular complexes (PVCs): May be unifocal, multifocal, or multiformed; may be isolated single events or couplets, triplets, or salvos (4-6 in row); may occur early in cycle (R-on-T), after T, or late in cycle (fuse w/next QRS = fusion beat) 7 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 7
■ Ventricular tachycardia (VT): Sustained (ÏŸ30 sec) vs. nonsus- tained; monomorphic vs. polymorphic vs. torsade-de-pointes (polymorphic associated w/LQTS; phasic variations QRS polarity; rate often ÏŸ200 bpm; may † VïŹb); AV dissociation vs. retrograde atrial capture; Consider wide complex tachycardia is VT if: AV dissociation, ⁄⁄⁄axis deviation, QRS morphology atypical for BBB, concordance (all precordial leads in same direction), regular rhythm (RR intervals equal, irregularly irregular rhythm suggests atrial ïŹbrillation Ï© aberration or Ï© WPW pre-excitation), QRS morphology ~pre- vious PVCs, very wide QRS complexes (ÏŸ0.16 sec), no RS V1-V6, beginning of R to nadir S ÏŸ0.1 sec in any RS lead Lumbar Puncture Indications ■ Dx CNS disease, administer CNS treatment or treat hydrocephalus Contraindications ■ ⁄Intracranial pressure (ICP); intracranial mass effect (r/o mass lesion: head CT when signs of ⁄ICP) ■ Bleeding dysfunction ■ Infection near site ■ Elderly: avoid fast and large volume withdrawals. Equipment ■ Skin preparation: sterile sponges, povidone-iodine swabs, and EtOH swabs ■ Mask, sterile ïŹeld (towels and drapes), and gloves ■ Local anesthetic, usu. lidocaine 1% plain ■ Syringe (3 mL) and needles (22-G Ï« 1.5”, 25-G Ï« 5/8”) ■ Spinal needles (both 18- and 20-G, 3” length) ■ Three-way stopcock, sterile collection tubes, and manometer ■ Gauze dressings and adhesive bandage Preparation ■ Sterile technique; skin preparation ■ Find L4-5 space (L4 at iliac crest level) 8 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 8
■ Local anesthesia: inïŹltrate skin (25-G needle), then Δ to 22-G needle and advance † inïŹltrate deeper tissue Patient Positioning ■ Lateral decubitus: (preferred): Lateral decubitus position at edge of bed, while maximally ïŹ‚exing knees (near chest), hips, and back (opens L3/L4 space) pt. shoulders and hips perpendicular to bed ■ Sitting: (easier for obese or spinal dz/deformity): Pt. sits at bed edge, leans over two pillows, ïŹ‚exes head Technique ■ Insert spinal needle into skin and slowly advance (keep per- pendicular to skin, hold w/two hands, keep stylet in place); feel “pop”; perforate ligamentum ïŹ‚avum; withdraw stylet, and look for CSF drainage ■ If no CSF and needle advanced Ïœ4 cm (in adult), advance 2 mm, remove stylet, and check for CSF drainage; repeat until get CSF or needle advanced ÏŸ4 cm (then withdraw and redirect needle) ■ Connect three-way stopcock, and attach manometer; measure opening pressure (normal 70-180 mm CSF) ■ Send ïŹ‚uid for studies; remove needle and dress wound; pt. remains supine Ն12 h (minimize headaches) Complications Brain herniation (⁄ ICP and mass), infection (meningitis or empyema), subdural hematoma (rapid withdrawal of large volume CSF), bloody tap, spinal epidural hematoma, headache, dry tap † needle may be too lateral or deep ■ For CSF interpretation see Labs Tab Cricothyroidotomy Indications ■ Emergent need for airway; airway obstruction above cricoid cartilage level, failed intubation, or laryngeal trauma, mass, or hematoma 9 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 9
Contraindications ■ Subglottic airway obstruction ■ Intubation possible ■ Uncorrectable coagulopathy Equipment ■ Suction ■ Local anesthesia (e.g., 1% lidocaine and 1:100,000 epinephrine) ■ Scalpel (ideally, No. 15 blade) ■ Retractors (Army-Navy or large vein refractors) ■ Kelly clamps ■ Suture (2-0 or 3-0 silk, 4-0 vicryl) ■ Cuffed tracheostomy tubes (preferable) or No. 4 or 5 small, ïŹ‚exible endotracheal (ET) tubes. Preparation ■ Palpate and locate cricothyroid ligament: between cricoid and thyroid cartilages (~1.5 cm inferior to thyroid cartilage); neck strap muscles lateral to ligament Patient Positioning ■ Neck extended (unless cervical injury) Technique ■ Sterilely prepare and drape skin ■ If enough time, inïŹltrate entry site with lidocaine ■ Scalpel † 3 cm horizontal (Ăžrisk of thyroid or cricothyroid cartilage damage) or vertical (better in obese when cannot palpate cricothyroid membrane) incision over center of cricothyroid membrane ■ Gently spread subcutaneous tissue w/clamp † expose cricothyroid membrane; may need retractors to spread neck strap muscles laterally ■ Avoid blood vessels, use scalpel to cut horizontally through membrane; may widen incision with clamp ■ Insert tracheostomy tube or endotracheal tube ■ InïŹ‚ate tube cuff; suture or tie down tube ■ Ventilate w/Ambu bag ■ Δ to formal tracheostomy Յ1 week (or risk stenosis) Complications ■ Bleeding, subglottic/glottic stenosis, chondritis 10 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 10
Endotracheal Intubation Indications ■ SigniïŹcant ⁄ CO2 or Ăž O2 from respiration ■ Protect airway or pulmonary toilet Contraindications ■ Only intubate if necessary ■ Inaccessible/damaged oral cavity/larynx † nasal intubation (if no coagulopathy, severe intranasal problems, basilar skull fracture, or CSF leak) ■ Cervical spine instability Equipment ■ Lubricant: Water-soluble 2% lidocaine jelly ■ Tape and skin adhesive ■ O2 and bag-valve-mask ventilation device (Ambu bag) ■ If available: O2 saturation monitor,in-line CO2 monitor ■ Suction apparatus, suction tubing, tips, catheters ■ Laryngoscope w/straight and/or curved blade ■ Endotracheal tubes; syringe (10 mL) † inïŹ‚ate cuff ■ Flexible metal stylet and Magill forceps ■ Anesthesia Recommended ET Parameters (for nasal: add 2 cm to each measurement) Pree- Neo- 1-2 4-6 8-12 Age mie nate 6 mo yr yr yr Adult ET Tube Diameter (cm) 2.5 3–3.5 3.5–4 4–5 5–5.5 6–7 7.5–8.5 Blade (cm) 0 0–1 1 1–2 2 2–3 4–5 Insert: Lips to Mid-Trachea (cm)† 10 11 11–12 12 Ï© (age/2) ©:~23 ÂȘ~21 11 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 11
Preparation ■ Rapid-sequence intubation: IV sedative (etomidate) † sedated, then IV muscle relaxant (succinylcholine); may add sedative (fentanyl or morphine), lidocaine, and/or ⁄⁄-lasting paralytic (vecuronium) ■ Awake intubation: Topical anesthetic, mild sedative and analgesic; stomach should be empty ■ Test laryngoscope; monitor HR, BP, and SaO2 Patient Positioning ■ Extend head and ïŹ‚ex neck; if possible (i.e., no cervical spine problem), place foam material, “doughnut”, or folded towel under occiput Technique ■ Ventilate pt. w/bag-valve-mask; assess airway ■ Remove foreign bodies (e.g., dentures) ■ Assistant: Continuously push back anterolateral cricoid carti- lage rim with ïŹrst and second ïŹngers until tube is placed ■ Open laryngoscope; use dominant hand to open mouth and nondominant hand to insert laryngoscope blade into right (left if left-handed) side of mouth ■ Sweep blade to midline tongue base (sweep tongue to other side); blade tip should be in valleculae (curved blade) or below epiglottis (straight blade) 12 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 12
■ Lift laryngoscope handle straight upward and forward † expose vocal cord; avoid lips, teeth, and trap tongue; using dominant hand pass lubricated ET tube through right (left if left-handed) corner of mouth and advance tip through vocal cords (while looking) ■ Remove stylet when proximal cuff ends at cord level ■ Advance tube into trachea; inïŹ‚ate cuff (~15 mm Hg); check placement: symmetric chest expansion, breath sounds both lungs (no breath in stomach) ■ Attach in-line CO2 monitor: Check for ⁄O2 saturation and CO2 in exhaled air ■ Secure tube w/tape (upper lip and cheek or neck) ■ Check chest x-ray (tip should be 4 cm above carina) ■ Once tube in place, longer-term sedation (aerosol benzocaine [20%] † tongue and posterior pharynx, midazolam or thiopental, fentanyl or morphine) Complications ■ Tube in esophagus or right mainstem bronchus ■ Aspiration (may Ăžrisk w/antacids, H2-blockers, metoclopramide, head-up positioning) ■ Damage to lips, teeth, tongue, airway Pericardiocentesis Indications ■ Cardiac tamponade ■ ⁄ pericardial effusion † Ăžhemodynamics Contraindications ■ Coagulopathy/bleeding dysfunction ■ Skin infection over needle insertion site Equipment ■ Skin preparation supplies, sterile gloves, towels/drapes ■ Local anesthetic (1% or 2% lidocaine, 25-G needle, 3-mL syringe) ■ Pulse oximeter, ECG monitoring (V lead) ■ 16- to 18-G spinal needle and No. 11 blade ■ 20-mL syringe and sample tubes 13 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 13
Preparation ■ Continuous ECG monitoring (30° semi-Fowler position pre- ferred); if V lead attached to pericardiocentesis needle † ⁄ sensitivity; an insulated wire with alligator clips at each end works well ■ Prepare skin; sterile technique; wear sterile gloves, mask, and gown; drape over xiphoid area ■ Local anesthesia (inïŹltrate skin 1%-2% lidocaine) Patient Positioning ■ Supine with thorax (i.e., head of bed) elevated 30-45 degrees Technique ■ Needle: Insert (2 cm below costal margin to left adjacent to xiphoid with blade) and direct (upward and posterior) at 45-degree angle for 4-5 cm; aim toward right (preferable) or left (⁄risk penetrate RV) scapular tip ■ Advance (aspirate continuously) needle until encounter ïŹ‚uid, check for cardiac pulsations, or ⁄ST on ECG. May feel needle enter cavity ■ Remove blood: (usu. 5-10 mL because most is clotted); if Ն20 mL, then probably in RV ■ If hemodynamics do not improve, then may need thoracotomy or local pericardial window excision ■ Send ïŹ‚uid for appropriate studies Complications Myocardial wall injury/penetration, myocardial infarction, pneu- mothorax, bowel perforation Arterial Line Indications ■ Hemodynamic monitoring ■ Arterial blood sampling ■ Frequent blood draws Contraindications ■ Infection or lesion at insertion point ■ Occlusion or thrombosis of artery 14 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 14
■ Uncorrectable coagulopathy ■ Systemic infection (use peripheral site) Equipment ■ Peripheral arterial line (with angiocatheter): Angiocatheter (20- or 22-G, 2” length) or arterial line kit, sterile scalpel ■ Femoral arterial line (Seldinger technique): Seldinger kit: needle (16-18 G), 10-mL syringe, guide wire, sterile scalpel, dilator, catheter ■ Skin preparation supplies ■ Local anesthetic (1%-2% lidocaine, 25-G needle, 3-mL syringe) ■ Sterile gloves, towels or drapes, dressing supplies ■ Heparinized saline (pressurized delivery system) ■ Blood gas syringe (for arterial blood sampling) ■ Another 5-mL syringe w/heparinized saline ■ Sutures ■ Arterial pressure monitoring equipment ■ Arm board w/terrycloth roll Preparation ■ Peripheral (radial): Nondominant hand: perform Allen test (compress radial and ulnar arteries † palm blanches; release ulnar artery and check reperfusion of palm; delay ÏŸ5 sec = abnl † choose another site) to conïŹrm collateral circulation ■ Use sterile technique; prepare and drape skin ■ Use lidocaine to inïŹltrate entry and suture points Patient Positioning ■ Peripheral: Usu. radial artery but can do dorsalis pedis; pt. seated and supine; immobilize wrist on arm board w/roll under wrist in slight dorsiïŹ‚exion ■ Femoral: Supine Technique Peripheral Arterial Line (Angiocatheter) ■ Locate pulse w/index ïŹnger of nondominant hand; small incision w/scalpel over entry site ■ Insert angiocatheter at 30°–45° to artery † bright pulsatile red blood freely † catheter; slowly advance catheter until ïŹ‚ow stops; withdraw slightly until blood pumps again; advance catheter over needle into vessel 15 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 15
Femoral Arterial Line (Seldinger Technique) ■ Locate pulse and make small incision w/scalpel ■ Connect 10-mL syringe to needle and insert needle at 45° to artery while aspirating on syringe ■ Insert and withdraw (while aspirating) needle until bright red blood pumps into syringe † detach syringe and use ïŹnger to block off hub of needle ■ Push guidewire through needle (should be no resistance); remove needle over wire ■ Cut incision larger so dilator can enter ■ Use dilator over wire to expand hole, then remove ■ Apply gentle pressure if bleeding ■ Push catheter over wire through hole into artery ■ Remove wire; check for bright red pulsatile blood in catheter hub For Peripheral or Femoral Arterial Line ■ If no blood, remove catheter and retry insertion; if still no blood, try ïŹ‚ushing needle w/heparinized saline; if not successful third time, try another site; cap catheter ■ Suture catheter to skin; draw blood samples prn and attach manometer; sterile dressing Removal of Arterial Line ■ Wear gloves; remove sutures, then catheter ■ ConïŹrm removed catheter is intact ■ Firm pressure to entry site for 10 min (longer when large lumen or anticoagulation) ■ After bleeding stopped, apply pressure dressing ■ Next day: check blood ïŹ‚ow to extremity Complications ■ Vessel perforation or thrombosis; limb ischemia* ■ Dislodged or loose connections to line ■ Incorrent placement or malfunction of line ■ Air embolus* ■ Infection, suppurative thrombophlebitis, sepsis* ■ Bleeding (apply pressure/additional sutures) 16 BASICSBASICS *Remove line immediately FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 16
Central Line Locations ■ Femoral vein: Easy access; far from airways and lungs, but area can be dirty and prevent pt. from walking ■ Internal jugular (IJ) vein: ĂžBleed risk, but poor landmarks and can puncture carotid artery ■ Subclavian vein: Comfortable; clear landmarks; but risk of pneumothorax or bleeding Indications ■ Hyperalimentation or long-term IV therapy ■ Give medications (e.g., vasoactive/inotropes, phlebitic) ■ Hemodialysis or rapid ïŹ‚uid administration ■ Intracardiac pacing ■ Central venous pressure monitoring Contraindications ■ Subclavian: ĂžPulmonary function (COPD, asthma), high levels of PEEP, coagulopathy, superior vena cava thrombosis, upper thoracic trauma ■ IJ: Tracheostomy, ⁄⁄⁄pulmonary secretions ■ Femoral: Vena caval compromise (clot, extrinsic compression, IVC ïŹlter), local infection, cardiac arrest or low ïŹ‚ow states, requirements for pt. mobility. Equipment ■ Central line kits are available ■ Skin preparation supplies (iodine, chlorhexidine, or EtOH) ■ Local anesthetic (1%-2% lidocaine, 25-G needle, 3-mL syringe) ■ Sterile gloves, dressings, towels or drapes ■ Supplies for Seldinger technique (or speciïŹc intravascular access kit) ■ Needle (16- to 18-G): For IJ lines, only insert needle 0.5-1.0” (ÏŸ1.5” may † pneumothorax); 10-mL syringe ■ Guidewire, scalpel, dilator, catheter ■ If the Seldinger technique is not used, a catheter-over-needle system may be used ■ Heparinized saline 17 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 17
■ Suture ■ Central venous pressure monitoring device ■ May need ultrasound if difïŹculty inserting Preparation ■ For both insertion and removal: Use sterile technique; sterile gown, hair cover, face mask/shield ■ Skin preparation; sterile drapes ■ Flush catheter w/saline ■ Liberally infuse area w/local anesthetic Patient Positioning ■ Femoral: Supine; stand on side of your dominant hand (right side of pt. if you are right-handed) ■ IJ: Supine; turn pt. head 45° away from insertion side; remove pillow from under pt. head and place pt. in Trendelenburg position ■ Subclavian: Trendelenburg position, remove pillow, towel roll between scapulae Insertion Points ■ Femoral vein: One ïŹnger breadth medial to artery and two ïŹn- ger breadths inferior to inguinal ligament; with bevel up and at 45°–60° above skin, insert needle parallel to vessel (steeper angle †þrisk of entering peritoneum; more medial insertion angle † less chance of needle entering femoral artery) ■ IJ: Lateral to carotid; Landmark: Apex of triangle (clavicle and two heads of sternocleidomastoid) OR between sternal notch and mastoid process; insert needle at 70° to skin, and aim for ipsilateral nipple ■ Subclavian: 2 cm inferior to junction of lateral third and medial two thirds of clavicle and 2 cm above suprasternal notch; ïŹnder needle may be too short to reach vein Needle Approach ■ Femoral vein: With bevel up and at 45°-60° above skin, insert needle parallel to vessel (steeper angle †þrisk of entering peritoneum; more medial insertion angle †þchance of enter- ing femoral artery) ■ IJ: Insert needle at 70° to skin and aim for ipsilateral nipple; aim lateral; if unsuccessful, withdraw and carefully go 18 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 18
slightly medial; reassess landmarks; can use long (~3”) angiocatheter instead of regular needle ■ Subclavian: Insert needle bevel up; guide placement w/ nondominant hand: place index ïŹnger at sternal notch and thumb at clavicle; keep needle parallel to ïŹ‚oor and ïŹrst aim for clavicle; when hit clavicle, walk needle down (push on needle tip; do not push on syringe) until just below clavicle; then advance needle 4-5 cm; once ïŹnd vein, rotate needle 90° so that bevel faces caudally; if no blood, withdraw and redirect more cephalad Technique ■ Make sure you continuously aspirate while advancing or withdrawing needle ■ Using appropriate insertion point and approach, locate vein w/ïŹnder needle (optional w/femoral vein) ■ Aspirate venous blood w/ïŹnder needle, then insert large-bore needle at same site and at same angle; use nondominant hand to grab needle hub and lower needle to parallel vein and aspirate again to reconïŹrm ïŹ‚ow (may use transducer to conïŹrm venous blood); hold needle in place, remove syringe, and thread guidewire into needle; check for ectopy ■ Remove needle over guidewire and continue to hold wire w/gauze; do not let go of guidewire until removed ■ Make incision 3–4 mm (w/scalpel) through skin and fascia; push dilator 3–4 cm over guidewire to expand subcutaneous tissue ■ Thread catheter over guidewire ■ Advance catheter and remove guidewire ■ Aspirate blood and ïŹ‚ush each port ■ Suture line in place and consider spacer in small pt ■ STAT chest x-ray to r/o PTX and check line placement Removing Central Lines ■ If line tunneled/trapped, may have to remove under ïŹ‚uoroscopy ■ Place pt. in Trendelenburg position (reverse Trendenlenburg for femoral lines) and remove any pillows ■ Remove all bandages, gauze, and all suture material ■ Pt. should hum or Valsalva maneuver during line removal ■ Apply sterile dressing (gauze and occlusive dressing) 19 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 19
Complications Nonplacement/misplacement/nonfunction of line, dislodged line, infection, suppurative thrombophlebitis, catheter-related sepsis, pneumothorax, catheter/guidewire embolism, air embolism, vessel thrombosis, central vein thrombosis, hemorrhage, arrhythmias, myocardial or central vein perforation, pericardial tamponade, infection, hematoma, subcutaneous emphysema or ïŹ‚uid inïŹltra- tion, arterial puncture/laceration, hemorrhage Swan-Ganz (SG) Catheters Indications ■ Acute heart failure or severe hypovolemia ■ Hemodynamic instability ■ Severe pulmonary disease ■ Sample blood and determine cardiac output Contraindications ■ Infection or lesion at entry point ■ Occlusion or thrombosis of desired vessel ■ Uncorrectable coagulopathy ■ Caution: systemic infection Equipment ■ Skin preparation (iodine, chlorhexidine, or EtOH) ■ Local anesthetic (1%–2% lidocaine, 25-G needle, 3-mL syringe) ■ Sterile gloves, towels or drapes, dressings ■ Seldinger supplies: Needle (16–18-G), syringe (10 mL), guide wire, scalpel, dilator, catheter ■ Catheter supplies: SG catheter, monitor, protective sheath, syringe (3 mL),heparinized saline ■ Sutures Preparation ■ Prepare and drape skin; sites: subclavian (preferred), internal jugular (preferred), or femoral veins ■ Local anesthesia: InïŹltrate skin entry site ■ SG catheter: Flush each lumen w/heparinized saline; check balloon (inïŹ‚ate w/1–1.5 mL air); attach pressure monitor and infusion ports 20 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 20
■ Keep catheter in protective plastic container until zeroing pro- cedure complete; remove catheter from plastic container and move tip w/wrist ïŹ‚ick † appropriate waveform (monitor screen) Patient Positioning ■ Subclavian or IJ: Supine and 15° Trendelenburg’s position; turn pt.’s head away from entry site; place roll under spine between shoulder blades ■ Femoral: Supine and ïŹ‚at Technique ■ Use sterile technique ■ Connect 10-mL syringe to needle; small incision w/scalpel; Seldinger technique: cannulate vessel w/needle, pass wire through needle into vessel (no resistance) and widen passage- way w/dilator; thread introducer over wire into incision ■ Remove wire and aspirate blood to conïŹrm placement ■ Flush w/normal saline or heparin solution ■ Tightly cap introducer; suture introducer to skin ■ Insert ïŹ‚ushed and zeroed SG catheter; another person needed to inïŹ‚ate/deïŹ‚ate balloon during placement ■ Thread catheter through sheath protector; move protector out of way to end of catheter ■ Watch pressure monitor while advancing catheter; when catheter tip clears introducer, inïŹ‚ate balloon † 1-1.5 mL; balloon ïŹ‚oats catheter w/blood ïŹ‚ow † RA and through heart; check for distinctive pressures ■ Further advance catheter † “wedge” balloon in PA 21 BASICSBASICS Right atrium Right ventricle Pulmonary artery Pulmonary capillary wedge pressure PressureinmmHg FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 21
■ When wedged, deïŹ‚ate balloon and conïŹrm return of pulsatile pulmonary artery pressures ■ ReinïŹ‚ate balloon and reconïŹrm wedge position ■ Record appropriate pressures ■ Pull protective sheath over catheter and attach to introducer; conïŹrm introducer well sutured and caps tight; chest x-ray to conïŹrm placement ■ Check every day for infection; Δ catheter over wire q3–7d If Catheter Does Not Place Easily ■ DeïŹ‚ate balloon, then pull catheter back and advance again; ïŹ‚ush catheter w/5-10 mL cold saline to stiffen; occasionally, ïŹ‚uoroscopy needed Removal ■ Wear gloves; pt. supine; deïŹ‚ate balloon ■ Slowly remove catheter; may leave introducer for venous access; clean entry site w/sterile soap ■ Remove sutures; remove IV lines from transducer; pt. holds breath while remove introducer; check that entire catheter removed ■ Firm pressure at entry point Ï« Ն10 min; if bleeding stops † occlusive dressing Ï« 24-48 hrs; culture catheter tip ■ Check site next day for infection or bleeding Complications See complications for central venous lines; in addition, may cause pulmonary artery perforation, pulmonary infarction, car- diac arrhythmias Thoracentesis Indications ■ Diagnostic: Most new effusions, unless clear clinical dx with no e/o pleural space infection ■ Therapeutic: Dyspnea from large pleural effusion; also may aid work-up of large effusion Contraindications ■ No absolute contraindications ■ May need platelets/factor replacement: e.g., platelets Ïœ50,000, PT/PTT ÏŸ 2 Ï« normal 22 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 22
■ Relative contraindication: Cellulitis or herpes zoster at needle puncture site ■ Caution: mechanical or manual ventilation Equipment ■ Sterile towel, gauze pads, dressing, drape w/fenestration ■ Basin for preparation solution ■ Syringe(s) (10-20 mL) ■ Needles (22- and 25-G) for inïŹltration ■ Povidone iodine ■ Local anesthetic (e.g., 1% lidocaine): 10 mL ■ Heparin: 1 mL ■ Atropine: Available at bedside (for vasovagal reaction) ■ Syringe (50- to 60-mL) for aspiration ■ Sterile drainage tubing ■ Three-way stopcock ■ Needle or needle catheter (depends on technique): Hypodermic needle (18–22-G, 1.5”–2”), over-the-needle catheter (16–20-G needle) or through-the-needle catheter (14–18-G needle) ■ Scalpel (needle catheter technique only) ■ Sterile specimen bowl or Vacutainer bottle ■ Analysis containers: Iced blood gas syringe, specimen tubes (red-top and purple-top), sterile transport media for culture or 10-mL sterile container, 5 red-top specimen tubes for cytology or 10- to 50-mL plain bottle Preparation ■ Start IV; draw serum protein and LDH ■ Pulse-oximetry monitoring; O2 as needed ■ Diagnostic: Premoisten 50– to 60-mL collection syringe with 1 mL heparin (100 U/mL) to prevent clotting ■ Sterile technique, prepare skin with antiseptic; place sterile towels/drape around site ■ Effusion height: Percussion and tactile fremitus Patient Positioning ■ Upright (preferred): Pt. sits erect on bed edge and extended arms rest on bedside table; large effusion † pt. leans forward slightly; insert needle posterior rib at least one interspace below top of effusion; midscapular or posterior axillary line y 23 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 23
■ Lateral decubitus: Effusion side down, back at bed edge; insert needle posterior axillary line ■ Supine: Head elevated; insert needle midaxillary; needle should not be lower than 8th intercostal space (ICS) Technique ■ Needle technique: (Diagnostic † only small volumes) simple 20- or 22-G needle ■ Needle catheter technique: Insert catheter over or through needle and leave in pleural space 1. Use 25-G needle and syringe w/5–10-mL anesthetic 2. Raise skin wheal at rib upper edge in midscapular or poste- rior axillary line 3. Δ 25-G † 3.75-cm 22-G needle (on anesthetic syringe) 4. Insert 22-G needle through wheal and inïŹltrate subcutaneous tissue, muscle, and rib periosteum 5. Advance needle 1-2 mm † aspirate subcutaneous tissue/muscle † inïŹltrate small amount anesthetic 6. Repeating step 5 † “walk” needle above rib’s superior edge and advance through ICS until † pleural space 7. Hold needle perpendicular to chest † avoid trauma to neurovascular bundle of adjacent rib 8. When enter pleural space (may feel “pop”), aspirate ïŹ‚uid to ensure pleural space reached 9. Withdraw needle (grasp with thumb and index ïŹnger) 10. No ïŹ‚uid † “dry tap” (i.e., missed area) 11. Air bubbles † enter lung parenchyma (too high) 12. Postprocedure chest x-ray Terminate Procedure When ■ Diagnostic: Removal 50-100 mL ïŹ‚uid ■ Therapeutic: Dyspnea relief or removal 1000 mL ïŹ‚uid ■ May remove larger volumes if monitor pleural pressures q200 mL for second liter and then q100 mL; terminate if pleural pressure ÏŸ -20 mm Hg ■ Aspirate air † suggests lung puncture or laceration, unless needle Ïœ 20-G (making pneumothorax unlikely) ■ Δ Sx: e.g., abdominal pain, ⁄SOB ■ Persistent cough 24 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 24
Complications Pneumothorax, cough, infection, hemothorax, splenic rupture, abdominal hemorrhage, unilateral pulmonary edema, air embolism, retained catheter fragment Light’s Criteria (Pleural Fluid = Exudate) 1) Pleural ïŹ‚uid:serum protein ratio ÏŸ0.5; 2) Pleural ïŹ‚uid LDH ÏŸ2/3 upper limit of normal serum LDH; 3) Pleural ïŹ‚uid:serum LDH ratio ÏŸ0.6 25 BASICSBASICS Special Pleural Fluid Assays Assay Diagnosis Suspected Amylase Pancreatitis, esophageal rupture Triglycerides Chylothorax, intrathoracic total parenteral nutrition Glucose Rheumatic effusion Urea or creatinine Urinothorax Cytology Malignancy Pleural Fluid Parapneumonic Empyema TB Malignant effusion PE/infarct Collagen vas- cular disease RA SLE Hemothorax Description Turbid Turbid, purulent Straw color, serosanguinous Turbid, bloody Straw color, bloody Turbid Green Yellow Bloody WBC Count ⁄ ⁄ Ïœ10,000 Ïœ10,000 ⁄ ⁄þ ⁄þ ⁄þ ⁄þ Main WBC PMNs PMNs Both Mono’s Both Both Both Both PMNs Glucose Ăž Ăž Ăž Ăž Serum ÞÞ Serum Serum pH ÏŸ7.3 Ïœ7.3 Ïœ7.4 Ïœ7.3 7.4 Ïœ7.3 ÏŸ7.3 Ïœ7.3 Diagnostic Features of Pleural Fluid FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 25
Nasogastric and Feeding Tubes Indications Nasogastric Tubes ■ Diagnostic gastric lavage: Check for GI bleed ■ Decompress stomach: Ileus, GI obstruction, persistent vomit- ing, preabdominal surgery ■ Removal toxins and pill fragments ■ Heating or cooling (temperature abnormalities) ■ Prevent aspiration (e.g., trauma) ■ Deliver medications, feedings, contrast, or charcoal Feeding Tubes ■ Enteral feeding or medication delivery Contraindications ■ Facial fracture: (Use mouth instead) ■ Possible cervical spine injury (use extreme caution) ■ For feeding tube only: Adynamic ileus, malabsorptive syndromes, intestinal obstruction, gastroenteritis Equipment ■ 16-18 Fr nasogastric tube or feeding tube ■ Lubricant jelly (K-Y or lidocaine) ■ Topical anesthetic (e.g., Hurricane spray)* and nasal vasoconstrictors (e.g., phenylephrine)* ■ Emesis basin; cup of water and straw ■ Catheter tip syringe ■ Suction apparatus ■ Gloves and eye protection, stethoscope, tape, benzoin Preparation ■ Wear gloves and eyewear when place or remove tube ■ Estimate tube length = patient’s ear to umbilicus ■ Premedication: Spray anesthetic † throat back; apply vasoconstrictor and topical anesthetic † nasal mucosa ■ Liberally apply lubricant along tube/tube tip 26 BASICSBASICS *Optional FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 26
Patient Positioning ■ Upright or decubitus, neck ïŹ‚exed Technique ■ Turn on suction apparatus (w/tonsil tip attached) ■ Pt. should hold emesis basin and cup of water ■ Insert tube in nostril toward occiput ■ Apply ïŹrm, constant pressure to tube while pt. takes small sips of water and swallows ■ Advance until two black lines on tube visible out of nares and nose between second and third black lines ■ Hold tube ïŹrmly in place close to nostril ■ Check placement in stomach: Attach catheter tip syringe to tube and inject 30-60 mL air; use stethoscope to hear air “whoosh” over epigastrium; use syringe to aspirate gastric ïŹ‚uid (normal pH Ïœ5) ■ Secure tube in two places (nose and second site like forehead or shoulder) w/benzoin and tape ■ Abdominal x-ray to conïŹrm placement (not necessary if suction applied) ■ Mark tube near nose to track proper placement ■ Record suction output volume and character For Feeding Tube Same procedure as nasogastric tube except: ■ Often need to place tube in duodenum or jejunem so: ■ Advance tube additional 20-40 cm ■ Pt. lays on right side for 8-12 hr ■ Fluid aspirate pH ÏŸ7 ■ May use metoclopramide or erythromycin to ⁄gastric motility † enhance tube passage ■ May need ïŹ‚uoroscopy to place ■ Do not use tube (or remove guidewire, if present) until check abdominal plain ïŹlm for placement Tube Removal ■ Disconnect tube from suction; remove tape ■ Pull steadily to remove tube; discard tube 27 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 27
Complications ■ ⁄⁄⁄Gagging during placement: spray more topical anesthetic to back of throat ■ DifïŹculty passing tube † tube stuck in nose (try other nos- tril), coils in mouth or esophagus (use ice to chill/stiffen tube) ■ Placement in lung (coughing): Remove immediately ■ Hypovolemia from ⁄⁄⁄nasogastric tube output: IV ïŹ‚uids 0.5–1 mL LR or NS and 30 mEq KCI/L for every mL of output ■ If tube blockage, try any or all of following: ■ Check tube: Inject air into vent port and listen for hissing (which is normal) ■ Disconnect/reconnect apparatus or reposition tube ■ Irrigate tube w/30–40 mL NS ■ Throat discomfort: Throat lozenges prn ■ Aspiration pneumonia ■ Trauma to nasal mucosa, nares, sinus oriïŹces († sinusitis), lung, esophagus, gastric mucosa ■ Tube too low (NGT drains drain bile) ■ Tube too high (⁄aspiration risk) Paracentesis Indications ■ Therapeutic: Massive ascites †þ respiration, pain ■ Diagnostic: distinguish transudative vs exudative ascites ■ Dx spontaneous bacterial peritonitis, malignant, chylous Contraindications ■ Coagulopathy ■ Abdominal adhesions ■ Agitation ■ SigniïŹcantly distended bowel ■ Pregnancy ■ Infection (e.g., cellulitis at insertion site) Equipment ■ Paracentesis kits available ■ Skin preparation supplies 28 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 28
■ Local anesthetic (1%–2% lidocaine, 25-G needle, 3-mL syringe) ■ Sterile gloves, towels or drapes, and dressing ■ Spinal needle (20-G) ■ Syringe or vacuum bottle ■ Scalpel, #11 blade ■ ButterïŹ‚y needle (Ն20-G with sterile tubing) Preparation ■ Decompress bladder (void or urinary catheterization) ■ ID ïŹ‚ank region (gas-ïŹlled bowel will ïŹ‚oat to top); avoid previous incisions ■ Prepare skin; sterile technique; prepare and drape skin ■ Local anesthesia: InïŹltrate skin entry site, lower fascial levels and peritoneum ■ Ultrasound guidance: If previous abdominal surgery or infection Patient Positioning ■ Supine or sitting (leaning forward: better w/small amount of ïŹ‚uid); raise bed so pt. is comfortable Technique ■ Sterile technique ■ Insert and advance 20-G spinal needle w/stylet until feel peritoneum “give” ■ Remove stylet; attach syringe and advance needle (5-mm increments) while aspirate until get ïŹ‚uid ■ If remove large volume: Connect tubing btween spinal needle and (butterïŹ‚y needle) vacuum bottle; placing soft catheter (Seldinger technique) into peritoneal cavity may help ■ Remove needle and sterile dry dressing over site ■ Send ïŹ‚uid for appropriate tests Complications ■ Perforate organ or blood vesel, bleed/hematoma, persistent site leakage, infection, leaving catheter in abdominal cavity, hypotension, dilutional ĂžNaÏ© , hepatorenal syndrome 29 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 29
Diagnostic Peritoneal Lavage (DPL) Indications ■ Acute abdominal trauma with coincident major nonabdominal injury (head injury, major fracture) ■ Critically ill pt. in whom an intra-abdominal source of fever or sepsis is suspected Contraindications ■ Multiple previous abdominal operations ■ Recent abdominal surgery, known abdominal adhesions, or obliteration of abdominal space from infection ■ Pregnancy ■ Caution: Dilated viscera (e.g., bowel loops) 30 BASICSBASICS Peritoneal Fluid Assays Assay Diagnosis Suspected Amylase Pancreatitic Triglycerides Chylous RBC count ÏŸ50.000/␟L Hemorrhagic ascites (malignancy, TB, or trauma) WBC ÏŸ350/␟L Infection (spontaneous bacterial peritonitis) PMNs Bacterial Mononuclear cells TB or fungal pHÏœ7 Infection Serum-Ascitic Albumin Gradient (SAAG) =AlbuminSerum–AlbuminAscites from same day High (Ն1.1 g/dL) Portal hypertension (transudative): CHF, cirrhosis, EtOH hepatitis, fulminant hepatic failure, portal-vein thrombosis Low (Ïœ1.1 g/dL) Exudative: Peritoneal carcinomatosis, pancreatic/biliary ascites, peritoneal TB, nephrotic syndrome, serositis, bowel obstruction/infarction FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 30
Equipment ■ Skin preparation supplies (povidone-iodine solution) ■ Mask, sterile sponges, towels and drapes, gown, gloves ■ Local anesthetic, preferably 1% lidocaine w/1:100,000 epinephrine ■ Syringe (5- or 10-mL) ■ Needles (21-G ϫ 1.5” and 25-G ϫ 1/8”) ■ Sterile surgical tray, include scalpels (Nos. 11 and 15), scissors, Kelly clamps, pickups, needle holders ■ Sutures (0 silk, 2-0 silk, #1 and 4-0 vicryl, and 4-0 nylon) ■ Peritoneal catheter and connection tubing ■ Normal saline ■ Dressing supplies Preparation ■ Decompress stomach (nasogastric or orogastric tube) ■ Empty urinary bladder (void or Foley catheter) ■ Prepare and drape skin ■ Entry site: usu. just caudal to umbilicus; if pelvic fracture, supraumbilical ■ If not unconscious/sedated, local anesthesia to skin entry site, lower fascial levels, and peritoneum Patient Positioning ■ Supine or (if therapeutic) sitting Technique ■ Use sterile technique ■ Open technique described here. [Alternative: Seldinger technique (insert needle † abdomen, pass wire over needle, dilate, and pass catheter through tract)] ■ 5-mm vertical incision (No. 11 blade) down to linea alba fascia; do not enter abdominal cavity ■ Expose linea alba and place stay suture on each side of fascia (0 silk); hemostat † “tag” each suture ■ Make 1 cm vertical incision in linea alba; enter peritoneal cavity using blunt dissection; retract abdominal wall w/blunt end of Senn retractor ■ Insert and direct catheter (always keep perpendicular to abdominal wall) † right or left iliac region 31 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 31
■ Never force catheter against resistance ■ Gently aspirate ïŹ‚uid into syringe through catheter ■ Attach 1-L sterile saline bag to catheter and empty bag into peritoneal cavity by gravity ■ Drop bag to ground and allow ïŹ‚uid to siphon out ■ Send all ïŹ‚uid to laboratory; remove catheter ■ Suture incision closed (deep fascia: stay sutures of 0 silk; skin: 4-0 vicryl for subcuticular dermal closure and 4-0 nylon for skin closure) Complications ĂžSensitivity to retroperitoneal injury, ⁄sensitivity to minor intraperi- toneal injuries, false negative (poor technique or diaphragmatic injuries), wound infection, false positive (bleeding from incision), Ăžsensitivity from prior DPL (introduce gas/ïŹ‚uid into abdomen), bleeding, viscous perforation Transurethral Catheterization Indications ■ Urinary retention (e.g., neurogenic bladder) ■ Urinary sampling ■ Monitor urinary output ■ Bladder irrigation or tests (e.g., cystogram) Contraindications ■ Ureteral stricture or disruption ■ Acute urethral or prostatic infection ■ Relative: Anticoagulated pt. (use ⁄⁄⁄lubricants and nontraumatic technique) Equipment ■ Skin preparation supplies (povidone-iodine solution) ■ Sterile gloves, gauze, sponges, towels ■ Water-soluble lubricant (may use lidocaine 2% jelly) ■ Syringe (10-mL); sterile water or saline (5 mL) ■ Adhesive tape ■ Urinary drainage system w/tubing and collection bag ■ Urinary catheter (usually 16- or 18-Fr Foley): 32 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 32
■ Foley: Double-lumen (larger † urine, smaller † balloon inïŹ‚ation): Usu. used to drain bladder ■ Straight (red Robinson): Straight catheterization ■ Coude: DifïŹcult cases; narrow, curved, ïŹrmer tip ■ 3-way irrigation: Retrograde bladder irrigation Preparation ■ Pretest balloon inïŹ‚ation w/saline ■ Skin preparation: Sterile technique; retract foreskin (if pres- ent) or spread labia (urethral meatus anterior to vagina and posterior to clitoris); prepare entire penis or periurethral area (including urethral meatus) w/Ն3 povidone-iodine applica- tions; keep one hand sterile while other holds penile shaft ■ Always lubricate catheter tip and shaft ■ May inject lidocaine 2% into urethra preinsertion Patient Positioning ■ Supine; male: penis straight upward; female: frog-leg position Technique ■ Always use sterile technique; insert and slowly advance catheter through urethral meatus (male: maintain continuous upward penile traction; retract penis caudally may help pass prostatic urethra) Straight catheter Foley catheter 3-way irrigation catheter Coude catheter 33 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 33
■ Urine drains † inïŹ‚ate balloon (5 mL of saline); no urine † push on bladder; never inïŹ‚ate balloon w/o urinary return († damaged urethra) ■ Do not attempt multiple passes; if cannot avoid multiple passes, use smaller or Coude catheter placement ■ Gently pull back catheter until mild resistance ■ Tape catheter to thigh w/slight catheter slack ■ Return foreskin to back over penis head Complications DifïŹculty passing catheter (from any lower GU structure/disruption or prostatic enlargement); Traumatic catheterization † hematuria, transurethral tear/false passage; infection Suprapubic Catheterization Indications ■ Pelvic trauma causing urethral tear or disruption ■ Need for bladder drainage in the presence of urethral or prostate infection ■ Acute urinary retention when transurethral catheterization not possible Contraindications ■ Nonpalpable bladder ■ Uncorrectable bleeding diatheses Equipment ■ Skin preparation supplies (povidone-iodine solution) ■ Local anesthetic (1% lidocaine Ïź epinephrine; 22-G, 1.5” needle, 10-mL syringe) ■ Razor ■ Sterile gloves, mask, gauze sponges, towels and sheets ■ No. 11 scalpel ■ Syringe (60-mL) ■ Suprapubic catheter (usu. 14-G, 12”); intracatheter needle; needle holder, scissors, and pickups ■ Suture (2-0 silk or nylon) ■ Adhesive tape ■ Urinary drainage system w/bag and tubing ■ Sterile dressings 34 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 34
Preparation ■ Local anesthetic agent Ïź IV sedation ■ Bladder must be distended and palpable ■ Shave umbilicus to pubis ■ Locate puncture site (midline, 4 cm above pubis) ■ Prepare skin w/alcohol solution ■ InïŹltrate skin, subcutaneous, abdominal wall, bladder wall w/local anesthetic ■ Prepare skin w/providone-iodine; sterile towels/drapes Patient Positioning ■ Supine w/roll under hips † extend abdomen and pelvis Technique ■ Always use sterile technique ■ Avoid multiple needle passes ■ Catheter-through-needle or sterile Seldinger technique ■ Shallow skin incision (No. 11 blade) ■ While aspirating, advance needle w/syringe through incision (at 60° to abdominal skin) until get urine ïŹ‚ow † syringe; remove syringe from needle ■ Thread intracath catheter through needle † bladder ■ Urine ïŹ‚ow in catheter † remove needle over catheter ■ Free ïŹ‚ow urine through catheter † suture catheter in place; attach urine collection device to catheter ■ Sterile dressing Complications DifïŹculty passing the suprapubic catheter, infection, traumatic placement, bowel perforation Arthrocentesis Indications ■ Dx septic joint or crystal-induced arthritis ■ Traumatic (blood in joint) vs inïŹ‚ammatory effusion ■ Dx intra-articular fracture (blood and fat globules) ■ Sx relief: Pain (hemarthrosis or tense effusion) ■ Give anti-inïŹ‚ammatory or local anesthetic medications 35 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 35
Contraindications ■ Infection in tissue overlying puncture site ■ Bacteremia ■ Bleeding diatheses ■ Joint prosthesis Equipment ■ Skin preparation supplies and sterile gloves, drapes, basin, cup, test tubes, gauze, dressings, saline hemostat ■ Local anesthetic ■ Syringes (2, 10, and 20 mL); needles (18, 20, 22, and 25G) ■ Three-way stopcock ■ Green-top tube w/liquid anticoagulant, microscope slides w/coverslips, culture media (for infection) Preparation ■ Carefully identify landmarks and choose puncture site (avoid nerves, tendons, major vessels) ■ Sterile technique; prepare skin (allow betadine solution to dry btween applications); remove betadine w/EtOH to prevent betadine † joint space ■ Δ gloves after skin preparation; apply sterile towels/drape ■ InïŹltrate skin w/local anesthetic (22-/25-G needle) Patient Positioning ■ For knee lateral approach: Supine on examination table, feet at right angle, knee slightly ïŹ‚exed (15°–20°), rolled towel under popliteal space ■ For knee patella tendon approach: Pt. sits upright with foot perpendicular to ïŹ‚oor Technique ■ Attach (18- to 22-G) needle to syringe and insert through skin, subcutaneous tissue, and into joint space ■ Knee lateral approach: Insert needle 1 cm superior/lateral to superior lateral patella; may use hand to grasp and elevate patella slightly; needle † under patella at 45° to midjoint area; should be no resistance ■ Other approaches: Enter through patella tendon or medially or laterally directly above joint line 36 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 36
■ Aspiration of synovial ïŹ‚uid conïŹrms joint space placement ■ If Δ syringe: Use hemostat to hold needle hub ■ Aspirate all joint space contents/ïŹ‚uid ■ Remove needle and dress wound; send ïŹ‚uid for tests ■ Larger effusions: Use larger syringe and consider using three-way stopcock (do not have to Δ syringe) Complications Infection, bleeding, anesthetic hypersensitivity. Fluid stops ïŹ‚owing (joint space drained, needle tip dislodged, or debris/clot obstruct tip), needle dislodged (slightly advance/retract needle, rotate bevel, or use Ăž pressure to aspirate), cartilage dam- age (from bouncing needle off bone) Abscess Incision and Drainage Indications ■ Palpable skin abscess (usu. ÏŸ5 mm) that does not resolve with conservative measures (warm soaks) 37 BASICSBASICS Monosodium urate (gout) Ca2Ï© pyrophosphate dihydrate (CPPD) Pseudogout Ca2Ï© phosphate (hydroxyapatite) Cholesterol Corticosteroids Strong negative birefringence, needle- shaped, long* Uricase digestion X-ray diffraction Weak and birefringence, rhomboid or small rods, pleomorphic* X-ray diffraction Not easily visualized* Electron microscopy X-ray diffraction Rhombic or platelike, notched corners, multicolor, occasionally small, needle- like* Chemical determination Pleomorphic; variable birefringence* Postintra-articular steroid Rx Joint Fluid Crystal Characteristics‡ Crystal Diagnosis *On polarizing microscope FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 37
Contraindications ■ Very large abscesses (may need operating room) ■ Deep abscesses in very sensitive areas (supralevator, ischiorectal, perirectal) ■ Locations: Palmar space, deep plantar spaces, nasolabial folds (may drain to sphenoid sinus) Equipment ■ Universal precautions materials ■ Local anesthesia: 1% or 2% lidocaine with epinephrine, 10-cc syringe and 25-G needle 38 BASICSBASICS Joint Fluid Characteristics‡ WBC Mucin Δ Glucose* Dx Appears /mL3 PMNs Clot (mg/dL) Normal Clear, pale 0–200 Ïœ10% Good ~0 yellow Group I (noninïŹ‚ammatory) DJD; Clear to 50–4K Ïœ30% Good ~0 traumatic slight turbid arthritis Group II (noninfectious, mildly inïŹ‚ammatory) SLE; Clear to 0–9K Ïœ20% Good ~0 scleroderma slightly (occasion- turbid ally fair) Group III (noninfectious severe inïŹ‚ammatory) Gout Turbid 100–160K ~70% Poor 10 Pseudogout Turbid 50–75K ~70% Fair/poor ? RA Turbid 250–80K ~70% Poor 30 Group IV (infectious inïŹ‚ammatory effusions) Acute Very turbid 150–250K ~90% Poor 90 bacterial TB TB 2500–100K ~60% Poor 70 *Mean difference between synovial ïŹ‚uid and blood glucose ‡Adapted from Cohen, AS. Cecil’s Tectbook of Medicine FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 38
39 BASICSBASICS ■ Skin preparation solution and sterile drapes ■ No. 11 scalpel blade with handle ■ Sterile gauze and tape ■ Hemostat, scissors ■ Packing strip (plain or iodoform, 1/2”) ■ Culture swab Preparation ■ Universal precautions; prepare skin and sterile drapes ■ InïŹltrate local anesthetic, allow 2–3 minutes for anesthetic to take effect Patient Positioning ■ Depends on abscess location Technique ■ Cut through skin into abscess w/wide incision (No. 11 blade); incision should follow skin fold lines ■ Allow pus to drain; soak up w/gauzes ■ Swab inside abscess cavity (culture swab) ■ Gently explore cavity w/hemostat, break up loculations ■ Pack abscess cavity; dress wound w/gauze and tape ■ May send pus for Gram stain and culture (commonly strepto- coccus, staphylococcus, or enterics (perianal), or anaerobic and gram-negatives. Complications Abscess actually sebaceous cyst or hematoma, no drainage, bleeding FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 39
40 H&P Cranial Nerve Major Functions How to Test I Olfactory Smell Odor II Optic Vision Vision chart III Oculomotor Most eye muscles Follow ïŹnger IV Trochlear Superior oblique Look down at (eye Ăž and out) nose V Trigeminal Face sensation Touch face Chewing muscles Clench teeth VI Abducens Lateral rectus Look to side (eye lateral) VII Facial Face expressions Smile Tears/saliva ⁄þEyebrows Taste (anterior 2/3 Sugar or salt tongue) VIII Vestibuloco- Hearing Tuning fork chlear Equillibrium ? Vertigo (auditory) IX Glossopharyn- Taste (posterior Gag reïŹ‚ex geal 1/3 tongue) Swallow Sense carotid BP Uvula position X Vagus Larynx/pharynx ? Hoarseness Parasympathetic Open wide, say Taste “AH” XI Spinal Trapezius/ Shoulder Accessory sternocleidomastoid shrug/raise Turn head XII Hypoglossal Move tongue Tongue out FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 40
41 H&P Distinguishing Causes Upper Lower of Motor Motor Motor Extra- Defects Neuron Neuron Muscle Cerebellar pyramidal ĂžStrength Ï© Ï© Ï© ÏȘ ÏȘ Atrophy ÏȘ ⁄⁄⁄ ⁄ ÏȘ ÏȘ Fasciculations ÏȘ Ï© ÏȘ ÏȘ ÏȘ Babinski’s Ï© ÏȘ ÏȘ ÏȘ ÏȘ ⁄Tone Ï© ÏȘ ÏȘ ÏȘ ÏȘ ĂžTone ÏȘ Ï© Ï©/ÏȘ ÏȘ ÏȘ HyperreïŹ‚exia Ï© ÏȘ ÏȘ ÏȘ ÏȘ HyporeïŹ‚exia ÏȘ Ï© Ï©/ÏȘ ÏȘ ÏȘ Clasp knife Ï© ÏȘ ÏȘ ÏȘ ÏȘ Ataxia ÏȘ ÏȘ ÏȘ Ï© ÏȘ Distinguishing Vestibular (peripheral VIII nerve), Cerebellar, and Sensory (afferent pathway: peripheral nerve to thalamus/ parietal lobe) Lesions Finding Vestibular Cerebellar Sensory Vertigo Ï© Ïź ÏȘ Nystagmus Ï© Often Ï© ÏȘ Dysarthria ÏȘ Ïź ÏȘ Limb ataxia ÏȘ Usual Ï© Ï© Stand feet together; Ï© ÏȘ Ï© eyes open Stand feet together; Ăž ÏȘ ÏȘ eyes closed Vibratory and position sense Ï© Ï© Ăž Ankle reïŹ‚exes Ï© Ï© Ăž (continued) FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 41
Lower Extremities Cannot toe walk when Ն50% loss S1 † gastrocnemius and anterior tibialis; cannot heel walk when Ն50% loss L4, L5 † tibialis anterior Sciatic Nerve Compression ■ Cross-leg (well leg) straight-raising test: Pt. lies supine and lifts uninvolved leg up with knee extended; positive: pain radiates posterior leg † foot ■ Straight leg-raising test: Like cross-leg but pt. lifts involved leg; positive: pain radiates back † below knee; hamstring problem: only posterior thigh pain Femoral Nerve Compression ■ Reverse leg-raising test: Pt. lies prone and extends involved leg with knee extended; if pain radiates anterior leg † foot, then femoral nerve compression Intrathecal Pathology ■ Milgram’s test: Pt. lies supine and raises legs ~5 cm and holds for 30 sec † stretches iliopsoas and anterior 42 H&P Distinguishing Causes Upper Lower of Motor Motor Motor Extra- Defects Neuron Neuron Muscle Cerebellar pyramidal Akinesia ÏȘ ÏȘ ÏȘ ÏȘ Ï©/ÏȘ Chorea or ÏȘ ÏȘ ÏȘ ÏȘ Ï©/ÏȘ athetosis Intention ÏȘ ÏȘ ÏȘ Ï©/ÏȘ ÏȘ tremor Resting tremor ÏȘ ÏȘ ÏȘ ÏȘ Ï©/ÏȘ FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 42
43 H&P abdominal muscles and ⁄ intrathecal pressure; if no leg pain, no intrathecal pathology ReïŹ‚exes Nerve ReïŹ‚ex Root Nerve Testing Jaw Pons Mandibular branch, trigeminal Tap mandible at down- ward angle w/mouth slightly open Biceps C5–6 Musculocu- taneous Tap biceps tendon w/arm ïŹ‚exed partially at elbow Brachiora- dialis C5–6 Radial Strike radius lower end just above wrist Normal: Elbow ïŹ‚exion Triceps C7–8 Radial Tap triceps tendon; support upper arm; let forearm hang Finger C8, T1 Median Either tap palm or hold pt.’s middle ïŹnger loosely and ïŹ‚ick ïŹngernail down † normal: ïŹnger slightly extends; abnormal: Hoffman’s sign (thumb ïŹ‚exes, adducts) Upper abdomen T7–10 Use blunt object to stroke abdomen lightly in and down Normal: Umbilicus deviates toward stimulus Lower abdomen T11–L1 (continued) FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 43
44 H&P Patellar L3–4 Femoral Strike patellar tendon Ankle (Achilles) S1–2 Tibial Tap Achilles tendon when pt. dorsiïŹ‚exes foot at ankle Normal: Plantar ïŹ‚exion Anal wink S2–4 Touch perianal skin Normal: Anus contracts Cremasteric reïŹ‚ex T12 Genital branch (gen- itofemoral) Stroke inner thigh Normal: Ipsilateral scrotal sac move ⁄ ReïŹ‚exes Nerve ReïŹ‚ex Root Nerve Testing FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 44
45 H&P Anterior thoracic rami Lateral thoracic rami Iliohypo- gastric Ilio- inguinal Obturator Lateral femoral cutaneous Anterior femoral cutaneous Medial femoral cutaneous Superficial peroneal Saphenous Sural Sural Tibial Lateral plantar Medial plantar Deep peroneal C2 C3 C4 C5 C6T1T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 C7 C8 S2 S3 Trigeminal Anterior cutaneous nerve neck Supraclavicular Axillary Lateral cutaneous nerve arm Median cutaneous nerve arm Lateral cutaneous nerve forearm Median cutaneous nerve forearm Radial Median Ulnar Saphenous Sole of foot Peripheral Nerves FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 45
46 H&P Sural Tibial Lateral plantar Medial plantar Saphenous Sole of foot Great occipital Lesser occipital Greater auricular Posterior rami of cervical nerves Axillary Supraclavicular Posterior cutaneous nerve forearm Lateral cutaneous nerve forearm Median cutaneous nerve arm Lateral thoracic rami Median cutaneous nerve forearm Radial Median Ulnar Posterior thoracic rami Posterior lumbar rami Posterior sacral rami Lateral femoral cutaneous Lateral femoral nerve of calf Superficial peroneal Sural Medial femoral cutaneous Calcaneal Saphenous Obturator C2 C3 C4 C5 C6 C7C8 T10 T12 L1 L2 L3 L4 L5 S3 S4 S5 S3 S4 S5 S1 S2 L2 L3 L4 L5 Peripheral Nerves FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 46
47 H&P Right Shoulder Liver Gallbladder Diaphragm Pancreas Cardiac Left Shoulder Lung Diaphragm (Kehr’s sign) Pancreas Cardiac Arm Cardiac Periumbilical Duodenum Appendix Suprapubic Bladder Uterus Groin/ Inner thigh Ureters Kidneys Jaw Cardiac Epigastric Duodenum Appendix Hiatal hernia Gallbladder and bile ducts Pancreas Referred Pain FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 47
Brain Circulation 48 H&P Anterior communicating artery Communicating artery Middle cerebral artery Anterior cerebral artery Posterior cerebral artery Basilar artery Internal carotid Vertebral artery Superior cerebellar Anterior inferior cerebellar Posterior inferior cerebellar Anterior spinal FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 48
Posterior cerebral Medial occipital and temporal cortex Posterior corpus callosum Upper midbrain Thalamus Superior cerebellar Upper cerebellum Upper pons Low midbrain Anterior inferior Upper cerebellum cerebellar Upper pons Low midbrain Posterior inferior Lower cerebellum cerebellar Medulla Anterior spinal (ASA) Anterior (ventral) spinal cord 49 H&P Main Artery Region of Brain Sustained Anterior cerebral Medial frontal and parietal Anterior corpus callosum Middle cerebral Lateral frontal, parietal, occipital, temporal cortex Lenticulostriate branches † caudate nucleus, putamen, upper internal capsule FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 49
50 H&P Frontal lobe problem solving, planning, apathy, inattention, aphasia, contralateral weakness, labile affect, Broca’s area Temporal lobe memory problems, aggressive sexual behavior Dominant: Wernicke’s aphasia Cerebellum ataxia, dysarthria, dysmetria, intention tremor, nystagmus, scanning speech Occipital lobe vision problems Parietal lobe contralateral sensation Dominant: reading, writing, or math ability Non-dominant: neglect, difficulty dressing Midbrain, Pons, Medulla CN 3–12 FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 50
51 H&P Macula Fovea Optic nerve Vitreous humor Optic disk Retina Sclera Conjuctiva Anterior chamber Cornea Pupil Iris Ciliary body Choroid Lens Zonule Optic nerve Left eye Left eye visual field Right eye visual field Right eye Optic chiasm Optic tract Optic radiation Striate cortex Lateral geniculate nucleus 1 1 3 3 2 2 4 4 5 5 Eye Examination FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 51
52 H&P Superior rectus CN3 Superior oblique CN4 Medial rectus CN3 Lateral rectus CN6 Inferior rectus CN3 Inferior oblique CN3 Optic nerve Macula Fovea Optic nerve (“blind spot”) Optic disk Blood vesselsOptic cup FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 52
53 H&P Weber’s test Rinne’s test Fork at midline forehead Bone conduction: Put fork on mastoid Normal: Sound Ï­ both ears Air conduction: Put fork near ear Abnormal: Sound lateralizes † Normal: Air conduction one ear † Ăžipsilateral conductive ÏŸ bone hearing or Ăžcontralateral Abnormal: Bone conduction sensorineural hearing ÏŸ air conduction, which results in Ăžconductive hearing Ear Examination Tuning Fork Tests Vertigo Dix-Hallpike test (Nylen-Barany test): Pt. sits on examination table and extends legs; turn pt.’s head 30°–45° to one side, and pt. quickly lies back so head hangs over table end; look for nystagmus; repeat whole procedure with head turned in opposite direction Positive: Nystagmus † benign paroxysmal positional vertigo FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 53
54 H&P Cardiac Manuevers Mechanism Maneuvers Right- Sided Murmurs Aortic Stenosis (AS) Mitral Regurgi- tation (MR) IHSS* Preload Venous return Inspiration, squatting, raise ⁄legs ⁄⁄ ⁄⁄ ÞÞ ÞÞ Expiration, Valsalva’s, standing, nitrates, diuretics ÞÞ ÞÞ ÞÞ ⁄⁄ Afterload Isometric hand grip ⁄⁄ ÞÞ ⁄⁄ ÞÞ ⁄⁄ Valsalva’s, vasodila- tors ÞÞ ÞÞ ÞÞ ⁄⁄þþ *IHSS Ï­ idiopathic hypertrophic subaortic stenosis FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 54
55 H&P Comments Diastole Early Mid Late Systole AS Heard best @ R base (radiate R carotid) AI Heard best @ 3rd/4th L ICS (if radiate R sternal border aortic root dilate, e.g., Marfan) MS MI TI VSD PDA MVP PS PI TS Early Mid Late Harsh Low Opening snap Rumble Opening snap Rumble Opening snap Systolic click Systolic click Blowing Blowing Second degree Machinery All MV murmurs heard best@ apex , S1. Can be confused with Austin Flint (AI: mid-diastolic murmur @ MV when blood enters from aorta & L atrium simultaneously; No OS) If LV volume (stand, Valsalva) earlier clicks, duration, intensity; if LV volume (squat, legs, hand grip) delay clicks, duration, intensity Radiate L axilla/back; severe MR S3; with isometric handgrip & stand squat Heard best @ 4th L sternal border; wide split S1; may with inspiration (Carvallo’s sign);TS often occurs with MS Heard best @ 4th L sternal border; may with inspiration (Carvallo’s sign); 1st degree rare; usually 2nd degree to pulm HTN Heard best @ L base; confused with venous hum; if pulmonary HTN, may disappear systolic murmur, pulmonic ejection sound Heard best @ L 3rd/4th ICS and along sternal border; NI S2 Heard best @ L 2nd ICS (radiate to L neck) + palpable thrill; wide split S2 Heard best @ L 2nd/3rd ICS; may during inspiration FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 55
56 H&P Heart Sound Causes S1 Soft: ĂžCardiac output, tachycardia, ⁄⁄⁄MR Loud: Hyperdynamic (fever, exercise), mitral stenosis, atrial myxoma S2 (Aortic) Soft: CalciïŹc AS Loud: Systemic hypertension (HTN), dilated aortic root S2 (Pulmonic) Loud: Pulmonary HTN S3 (Low frequency, ⁄Atrial pressure â€ â„ïŹ‚ow rates (congestive early diastole) heart failure [CHF] most common, valvular regurge, left † right shunts) Normal in age Ïœ40 yr Jugular Venous Pressure (JVP) S1 S2 A APP S1 S2 Type Causes Inspiration Expiration Normal or physiologic Wide, fixed, splitting Wide split, varies with inspiration Paradoxical splitting Intrathoracic pressure Atrial septal defect Pulmonary stenosis RBBB Hypertrophic cardiomyopathy A P A P A P P A A P PA Adapted from University of Washington Advanced Physical Diagnosis Learning and Teaching at the Bedside, Edition 1. S4 (Low-frequency Stiffened LV (HTN, AS, ischemic or presystolic portion hypertrophic cardiomyopathy, acute MR of diastole) from chorda tendinea rupture) FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 56
57 H&P 45° Right atrium Sternum Jugular vein a c v x y Maximal atrial filling Small and usually not visible TV opening and atrial emptying RV contraction and TV closure R atrial contraction ‱ Fluid overload ‱ Blockage before heart (SVC obstruction) ‱ CO (e.g., HR, constrictive pericarditis, R heart failure pericardial effusion, TS or TI, cardial tamponade) ‱ Hyperdynamic circulation JVP FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 57
58 H&P Sign Causes Kussmaul’s (during inspiration, Constrictive pericarditis JVP ⁄distention; Ăžin normal pt.) (negative in cardiac tamponade) Severe right heart failure Hepatojugular reïŹ‚ux (push Right ventricular failure if liver † ⁄venous return to right JVP remains elevated atrium) (transient only in normal pt.) Absent A waves Atrial ïŹbrillation Sinus tachycardia Dominant A waves Pulmonary HTN Pulmonary stenosis Tricuspid stenosis Right atrial myxoma Cannon A wave (very large Ventricular tachycardia A waves) Complete heart block Paroxysmal nodal tachycardia Dominant V wave Tricuspid regurgitation Absent X descent Atrial ïŹbrillation Exaggerated X descent Cardiac tamponade Constrictive pericarditis Large CV waves Tricuspid regurgitation Constrictive percarditis Sharp Y descent Constrictive pericarditis Tricuspid regurgitation Slow Y descent Right atrial myxoma Tricuspid stenosis Absent Y waves Cardiac tamponade Abdominal Examination FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 58
59 H&P RUQ Biliary colic Cholecystitis Duodenal ulcer Hepatitis RLL pneumonia LUQ Gastritis LLL pneumonia Pancreatitis Splenic problems Periumbilical Appendicitis Gastroenteritis Mesenteric lymphadenitis Myocardial ischemia or infarction Pancreatitis Back Acute pancreatitis Posterior duodenal ulcer Retrocecal appendicitis Ruptured AAA LLQ Diverticulitis Ectopic pregnancy Ovarian cyst Ovarian torsion Tubo-ovarian abscess RLQ Appendicitis Cecal diverticulitis Ectopic pregnancy Ovarian cyst Ovarian torsion Tubo-ovarian abscess Flank Abdominal aortic aneurysm Pylelonephritis Renal colic Suprapubic Ectopic pregnancy Endometriosis Mittelschmerz PID Ovarian cyst Uterine leiomyoma UTI McBurney’s point FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 59
60 H&P Abdominal Physical Examination Findings Appendicitis ■ Psoas’ sign: Place hand above pt.’s right knee; ask pt. to ïŹ‚ex right hip against resistance † pain ■ Obturator sign: Raise the pt.’s right leg with the knee ïŹ‚exed; rotate leg internally at hip ■ McBurney’s sign: Tenderness right abdomen two-thirds distance from anterior iliac spine to umbilicus ■ Rovsing’s sign: Palpate LLQ † RLQ pain Gallbladder Disorders ■ Murphy’s sign: In cholecystitis; pt. breathes out; palpate below right costal margin at midclavicular line; pt. inspires † gallbladder moves down, hits your hands; if gallbladder ten- der then pt. will stop inspiration † Ï© test; negative in chole- docholithiasis and ascending cholangitis ■ Charcot’s triad: In cholangitis; RUQ pain, fever, chills, jaundice Retroperitoneal Hemorrhage ■ Cullen’s sign: Bluish periumbilical discoloration ■ Grey Turner’s sign: Flank discoloration Vaginitis Candida Vulvovaginitis ■ Discharge: Dry cottage cheese–like ■ Symptoms: Vaginal/vulvar pruritus, irritation, burning, sore ■ Examination: Vulva: red, edema, and adherent white clumps Bacterial Vaginosis Amsel’s criteria (3 of 4 needed for diagnosis): ■ Discharge: Gray-white, thin, homogenous, adherent ■ Vaginal pH ÏŸ4.5 (normal pH: 3.8–4.5) ■ Clue cells: Bacteria-coated vaginal epithelial cells ■ Ï© Whiff (amine) test: KOH Ï© discharge † ïŹshy odor Trichomonas Vaginitis ■ Discharge: ⁄⁄⁄, grayish-green, frothy (CO2 bubbles) ■ Symptoms: Vulvar/vaginal pruritus, irritation, edema FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 60
■ Examination: strawberry cervix (punctate hemorrhage), pH ÏŸ5.0, Ï© whiff test, wet preparation (vaginal vault, not endocervix): Motile, ïŹ‚agellated trichomonads Atrophic Vaginitis ■ Discharge: Thin or clear ■ Symptoms: Vaginal irritation ■ Examination: Vagina/vulva: pale, dry, thin, ÞÞrugae, pH 5–7 Scrotal Complaints Epididymitis Ï­ Chlamydia, Gonorrhea, or E. coli ■ Insidious onset; dysuria, frequency, urethral discharge; swollen/tender upper posterior testicle ■ Rx: Antibiotics Torsion Ï­ Testis Twists on Spermatic Cord Axis ■ Surgical emergency: Sudden onset; abnormal testis elevation/ axis; “bell clapper” deformity (congenital unanchored swinging testis); absent cremasteric reïŹ‚ex and Prehn’s sign 61 H&P Spermatic cord Testicular veins Testicular artery Vas deferens Epididymis Testicle Hydrocele Torsion Varicocele Spermatocele Epididymitis FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 61
Appendage Torsion Ï­ Twists on Testicular Appendage ■ Subacute symptoms, ïŹrm tender nodule upper pole epididymis; “blue dot sign” (blue/black spot visible beneath skin on testis/epididymis cranial aspect) ■ Rx: Bedrest and scrotal elevation Traumatic Injury Ï­ Epididymitis, Hematoma, or Rupture ■ Trauma history, ecchymosis, edema ■ Rx: Surgery if: uncertain diagnosis, ?testicle injury, disruption of tunica albuginea, or no ïŹ‚ow Doppler ultrasound Hydrocele Ï­ Fluid-Filled Sac Around Testis ■ Painless, ⁄size/tenseness from morning waking to later in day; transillumination: translucent ïŹ‚uid ■ Rx: Most resolve spontaneously; surgery if discomfort or tense hydrocele † testicle atrophy Varicocele Ï­ Abnormal Tortuous/Dilated Veins ■ Swelling, dull heaviness, ⁄ with exercise; no scrotal skin change; palpable “bag of worms” ■ Rx: May † infertility; scrotal support or surgery; ?obstructing mass if sudden onset in older pt. Spermatocele Ï­ Benign Cystic Sperm Accumulation ■ Asymptomatic: Painless, freely movable nodule superior to and separate from testis; transilluminates easily ■ Rx: None, unless bothersome 62 H&P FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 62
Tanner Stages IIIIIIIVV Ïœ10y.o.10–11y.o.12–14y.o.13–15y.o.16Ï©y.o. NoneSmallamount;Dark,coarse,Adultquality;Adult(extends long,downy,startstocurlnotedistributiontomedial slightlyandextend(sparemedialthigh) pigmentedlaterallythighs) MalePubicHair (continued) 63 H&P FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 63
64 H&P IIIIIIIVV Ïœ10y.o.10–11y.o.12–14y.o.13–15y.o.16Ï©y.o. NoAreolawidens;⁄Elevated,extends⁄Size,⁄elevation;Adult;areola buddingbudding,smallbeyondareolarareolaÏ©papillabacktobreast glandulartissueborders;areolaformsecondarycontour; surroundswidensmoundpapillaprojects Testicle1.6–6mL;skin6–12mL;12–20mL,ÏŸ20mL, volumethins,reddens,penis⁄⁄Scrotumadult Ïœ1.5mL;enlarges;penis:lengthens(anddarkens); penisnochangepenis:⁄length, small⁄circumference Breast Female Testicles FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 64
Stages of Labor 65 H&P Cervical Comments Duration Dilation Contractions ⁄ frequency, Most 0–4 cm strength,and regularity; variable cervical thinning or hours to effacement days Most rapid cervical Average 4–10 cm dilation nulliparous: 5 hr; multiparous: 2 hr 1st Stage ActiveLatent May blend into active 15 min–3 hr 7–10 cm; phase; more rapid descent; slower baby passes lower into pace pelvis and deeper into birth canal; when no anesthesia, often vomiting and shaking Female actively pushes Nulliparous: Complete out baby 2–3 hr Nulliparous: ÏŸ1 cm/hr Multiparous: Multiparous: ÏŸ2 cm/hr Ïœ1 hr Accelerated by Ïœ1–30 min breastfeeding (release oxytocin) or pitocin 2ndStage (birth) Transition (Deceleration) 3rdStage (placenta delivery) FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 65
66 H&P Placenta Umbilical cord Uterus Cervix Blood Placenta abruptia More common when mother has high blood pressure or uses cocaine Placenta previa Usually in multiparous women or uterine structural abnormalities (e.g., fibroids) Placenta prematurely detaches (incompletely or completely) Placenta implants over or near cervix FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 66
67 H&P x The cephalic or vertex presentation (normal) Usually normal vaginal delivery Seated or full breech position Usually normal vaginal delivery The transverse position (rare) Usually shoulder first to present; usually cesarean section required Frank breech position ‱ Vertical or longitudinal lie ‱ Vertical or longitudinal lie ‱ Vertical or longitudinal lie ‱ Legs pointed straight upward ‱ Limbs to chest ‱ Neck flexed Front Front Back Back FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 67
68 H&P Frontal bone Frontal bone Parietal bone Parietal bone Occipital bone Lambdoidal suture Sagittal suture Coronal suture Metopic suture Anterior fontanelle (closes at age 18–24 months, may bulge with crying or ICP) Posterior fontanelle (closes at 2 months) Back Front Obstetric Visits and Testing Timeline FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 68
69 H&P 010 162428323537 203040 HgB/HCT,bloodtype,Rhantibody screen,RPR/VDRL,rubellaAb,hep BsAg,UA,urineC&S,Pap(thin prep),wetprep,PPD,HIV,TSH, gonorrhea,chlamydia Sicklecell,Tay-Sachs,cysticfibrosis,VZV,geneticscreen,andurinetoxscreens 4regularcontractionsin20minutesor8regularcontractionsin60minuteswithPROM withprogressiveeffacement>80%andcervicaldilation>1cm Gonorrhea,chlamydia, groupBstrepcx InitialVisitLabs Uterussize Ultrasound Pretermlabor Biophysical profile Pregnancy- associated plasmaprotein TripleScreen: ␀-HCG,AFP, estradiol One-hour glucolatest Non-stresstest RhoGAM OBVisits Weeks Every4weeks Fetalhearttone withDoppler Fetal heart tone Fundalheight &toxemia signs Q2–4wksQ0.5–1wkQ1–2 General SymphysispubisMidpointSpubis/umbilicusUmbilicusSize(cm)=Weekofgestation IfRh(–) Optional GestationalageFetalsurveyprn If>140&3hrwnl,thenrepeat @32wks Fetalmovement FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 69
Skin Examination Lesion Descriptions ■ Macule: Flat; different color; can be seen, not felt ■ Excoriation: Mechanical skin erosion or destruction ■ LicheniïŹcation: Chronic irritation † leathery skin thickening with induration and hyperkeratosis ■ Onycholysis: Nail substance loosening or loss ■ Plaque: Flat, elevated, usu. ÏŸ5 mm ■ Solid raised, discrete: Papule (Յ5 mm), nodule (ÏŸ5 mm), pustule (pus-ïŹlled) ■ Blister: Fluid-ïŹlled vesicle (Յ5 mm), bulla (ÏŸ5 mm) Shoulder Examination Range of Motion (ROM) ■ Adhesive capsulitis (frozen shoulder): Stiffness, pain, and Ăžrange of movement; scar tissue forms post surgery or injury; develops when stop using joint from pain, injury, or chronic health condition (e.g., diabetes or arthritis) ■ Labral tears: Labrum Ï­ cartilage disk on glenoid; pain at back or in front on top of shoulder; feels deep inside; palpation does not duplicate pain; pain or “clunking” sound with overhead motion; causes: fall on outstretched arm, forceful lifting, or repetitive throwing Abduction/external rotation: Pt. places hand behind head and reaches as far down spine as possible; extent of reach should be at least ~C7 level; Forward ïŹ‚exion: Pt. traces out arc while reaching forward (elbow straight); should be able to move hand to a position over head; normal range 0–180° Extension: Ask pt. to reverse direction and trace an arc backward (elbow straight); pt. should be able to position hand behind back Appley scratch test (adduction and internal rotation): Ask pt. to place hand behind back and reach as high up spine as possible; note extent of reach relative to scapula/thoracic spine (should be at least T7); see ïŹgure for additional parts of examination 70 H&P FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 70
71 H&P FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 71
72 H&P Impingement (of Rotator Cuff Tendons) InïŹ‚ammation (tendonitis, bursitis), bone spurs, or â„ïŹ‚uid † squeez- ing rotator cuff (supraspinatus) tendon against bone (acromion); tendon may have tiny tears † scar tissue † further damage; night- time shoulder pain Neers’ test: Place your hand on pt. scapula; use other hand to hold pt. forearm; internally rotate pt. arm so that pt. thumb points downward; ïŹ‚ex pt. arm forward to position hand over head; pos- itive: pain Hawkin’s (for more subtle impingement): Raise pt. arm to 90° for- ward ïŹ‚exion; rotate it internally (i.e., thumb pointed down); puts humerus greater tubercle position to further compromise space beneath acromion; positive: pain FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 72
73 H&P - Biceps Yergason’s test: Flex pt. elbow 90°; pt. resists while externally rotate arm; if pain in biceps tendon † positive test † biceps tendon injury Rotator Cuff Tear ■ “Rotator cuff” Ï­ four tendons Ï­ supraspinatus (most common injured), infraspinatus, subscapularis, teres minor; muscles originate from scapula † single tendon unit insert- ing on humerus greater tuberosity ■ Repetitive overhead work or sports activity (e.g., painting, swimmers) ■ Gradual or acute onset; pain, stiffness; difïŹculty reaching overhead or behind back; may be snapping sensation Gerber’s liftoff test (check subscapularis function): Pt. places hand behind back, with palm facing out; pt. lifts hand away from back; partial tear will limit movement or cause pain; complete tears prevent movement Drop arm test for supraspinatus tears: Fully abduct pt.’s arm so that hand is over head; have pt. slowly lower arm to side; if suprapinatus torn, at ~90° arm will seem to drop suddenly toward body “Empty can” test for supraspinatus weakness: With elbows extended, thumbs pointing downward, and arms abducted to 90° in forward ïŹ‚exion, pt. attempts to elevate arms against examiner resistance Acromioclavicular Joint Dysfunction Cross-arm test: Pt. raises arm to 90°, then actively abducts, attempting to touch opposite shoulder; pain suggests problem FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 73
74 H&P Glenohumeral Joint Instability “Giving way” feeling or periodic shoulder dislocation; cannot keep humeral head centered in glenoid socket; shoulder pain in throw- ing athletes; anterior glenohumeral joint pain and impingement Sulcus test: With arm extened and at rest at pt.’s side, exert downward traction on humerus, and watch for sulcus or depres- sion lateral/inferior to acromion ■ Apprehension tests: Put humeral head in imminent subluxation or dislocation † pt. shows fear ■ Crank (pt. sitting or standing) or fulcrum (pt. supine) test: Place arm in extreme abduction and external rotation, which may cause apprehension ■ Relocation test: Pt. supine. ■ First part (fulcrum test): Push humeral head forward ■ Second part: Push humeral head posteriorly † prevents anterior subluxation † negative apprehension test ■ Inferior apprehension test: Hold upper limb in abduction, with pt.’s forearm resting on your shoulder; exert downward pressure over humeral neck; if shoulder unstable, head will be pushed down and groove appears Knee Examination Anterior Cruciate Ligament (ACL) Anterior drawer: Flex knee ~80°; relax hamstrings; stabilize foot; leg in neutral rotation; pull proximal tibia forward to see anterior FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 74
75 H&P displacement; quantify displacement (mm), and grade end point: hard (anterior cruciate ligament [ACL] halts forward motion) or soft (no ACL) Lachman’s: Anterior drawer variant; ïŹ‚ex (15°–20°) and externally rotate (relax iliotibial [IT] band) knee; one hand holds inner calf, and other hand holds outer aspect distal thigh; pull tibia anteriorly Pivot shift: Slight distal traction on leg; apply valgus and internal rotation force to extended knee; (no ACL † tibia anteriorly sub- luxes on distal femur); ïŹ‚ex knee ÏŸ30° (IT band † extendor † ïŹ‚exor of knee and tibial anterolateral subluxation reduces) Posterior Cruciate Ligament (PCL) Tibial drop back test: Flex knee 80°; compare proximal tibial prominence to femoral condyles; PCL-deïŹcient knee † gravity subluxes knee posteriorly; normal knee: tibial plateau located approximately 1 cm anterior to femoral condyles Quadriceps active test: Starting position: ïŹ‚ex knee 80°, neutral rotation; apply counterpressure against ankle while pt. ïŹres quadriceps muscle (i.e., tries to straighten leg); quadriceps pulls anteriorly through the tibial tubercle to reduce any posterior FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 75
translation in the knee; if PCL injured, then will see reduction of a posteriorly subluxed tibia with quadriceps contraction Posterior drawer test: Flex knee 80°, palpate hamstrings to ensure they are relaxed; stabilize foot and keep in neutral rotation; push tibia posteriorly; if PCL-deïŹcient knee Meniscus MacMurray’s test: Place thumb and ïŹnger on joint line; watch face for pain; ïŹ‚ex leg, externally rotate foot, abduct and extend leg to test medial meniscal “clicks”; ïŹ‚ex leg, internally rotate and adduct for lateral meniscal “clicks” Squat test: During full squat, check joint line tenderness and rotate each leg internally (test lateral meniscus) and externally (test medial mensiscus) 76 H&P FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 76
77 H&P Patella Bulge test: Check for effusion; press down patella † empty suprapatellar pouch; wipe hand along medial side to displace ïŹ‚uid laterally; compress lateral side, and watch for bulge medially Effusion: tap test: Push sharply on patella; if effusion, patella will bounce off femur Patellar tilt test: With knee ïŹ‚exed 20°, use thumb to ïŹ‚ip up lateral edge of patella; normally can tilt patella up above hori- zontal; excessively tight lateral retinaculum † no upward movement Soloman’s test: Lift patella away from femur; synovial thickening † patella hard to grasp Patellar compression test: Attempts to correlate anterior knee pain w/articular degeneration; compress patella down into trochlear groove as pt. ïŹ‚exes and extends knee Lateral patellar apprehension test: Flex knee 45°; keep knee relaxed; use one hand to stabilize leg while using other hand to apply lateral pressure to patella Medial patellar apprehension test: Fully extend knee; apply medial translation force; medial subluxation, which most often occurs in a pt. after a lateral release, occurs in the initial ïŹ‚exion arc of 0°–30°; after this point, the patella reduces into the bony conïŹnes of the trochlear groove when the knee is ïŹ‚exed Patellar displacement (Sage sign): Normally can displace patella medially and laterally 25%–50% of patellar width; ⁄movement † loose patellar restraints (frequent in adolescent females) Suprapatellar plica snap test: Palpate medial suprapatellar plica midway between medial patellar border and adductor tubercle; roll plica under your ïŹngers while assessing pain/inïŹ‚ammation FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 77
78 H&P Upper and Lower Extremity Muscles Part Action Muscle Root Nerve Arm Externally Infraspinatus C5 Suprascapular rotate Abduct Supraspinatus Deltoid C5 Axillary Elbow Flex Biceps C5–6 Musculocuta- neous Brachioradialis Radial Extend Triceps C8 Radial Wrist Extend Extensor carpi C6–7 Radial radialis longus Extensor carpi C7 ulnaris Flexor carpi ulnaris C8 Ulnar Flex Flexor carpi radialis C6–7 Median Finger Extend Extensor digitorum C7 Radial 5th Abduct 1st dorsal T1 Ulnar Finger interosseous Abduct digiti minimi Thumb Abduct Abductor pollicis T1 Median brevis Oppose Opponens pollicis Median Hip Extend Gluteus maximus L5–S2 Inferior gluteal Flex Iliopsoas L2,L3 Femoral Abduct Gluteus medius and L4–S1 Superior minimus, tensor gluteal fasciae latae Thigh Abduct Abductors L2–4 Obturator FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 78
79 H&P Part Action Muscle Root Nerve Knee Extend Quadriceps femoris L3–4 Femoral Flex Hamstrings L5–S1 Sciatic Ankle Dorsi Tibialis anterior L4–5 Peroneal (ïŹ‚ex) Plantar Gastrocnemius S1–2 Tibial Soleus Foot Evert Peronei L5–S1 Peroneal Invert Tibialis posterior L4 Tibial Toes DorsiïŹ‚ex Extensor digitorum L5–S1 Peroneal longus Extensor digitorum S1 brevis FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 79
80 ALGOR Algorithms Hyperprolactinemia (Ïœ100 ng/mL) ■ Ectopic production ■ Breast stimulation (e.g., breastfeeding) ■ Δ metabolism (liver failure, renal failure) ■ Hypothyroidism ■ Medications (e.g., oral contraceptives, antipsychotics, antide- pressants, antihypertensives, H2-receptor blockers, opiates) Hyperprolactinemia (ÏŸ100 ng/mL) ■ Prolactin ■ Empty sella syndrome ■ Pituitary adenoma Normogonadotropic Hypogonadism (⁄⁄Androgens) ■ Polycystic ovary syndrome ■ Androgen-secreting tumor (ovarian or adrenal) ■ Cushing’s disease ■ Nonclassic congenital adrenal hyperplasia ■ Exogenous androgens ■ Thyroid disease ■ Acromegaly Uterine OutïŹ‚ow Obstruction ■ Asherman’s syndrome ■ Cervical stenosis Hypergonadotropic Hypogonadism (Ovarian Failure) ■ Postmenopausal ■ Premature failure: e.g., autoimmune, chemotherapy, galactosemia, genetic, 17-hydroxylase deïŹciency syndrome, mumps, pelvic radiation FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 80
81 ALGOR Breastdevelopment& femaleTannerstage Pelvic ultrasound Uterineoutflow obstruction? Mullerian dysgenesis Pituitary defect GnRH deficiency Buccal smear Puregonadal dysgenesis Male pseudohermaphrodite Polycysticovary syndrome Adrenalor ovariantumor Second-Degree Amenorrhea Imperforate hymen Transverse vaginalseptum Hyperandrogenism?Karyotype Karyotype Height LH FSH Turner’s PrimaryAmenorrhea NormalAbnormal Uterus Nouterus 46XX Yes No NoYes 46XY 46XX46X0 Abnormal Normal <5 ng/mL <5 ng/mL >40 ng/mL >40 ng/mL Short Normal FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 81
82 ALGOR SecondaryAmenorrhea Uterineoutflow obstruction? Hyperprolactinemia Pregnancytest FSH LH Prolactin TSH Pregnancy Thyroid disease Normogonadotropichypogonadism Hypogonadotropic hypogonadism Hypergonadotropic hypogonadism (ovarianfailure) Estrogen/progestogenchallenge Abnormal Normal – + Nobleeding Nobleeding Vaginalbleeding <7days Vaginalbleeding<7days Vaginalbleeding <5ng/mL>40ng/mL <5ng/mL>20ng/mL Progestin challenge FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 82
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[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide
[] Medical notes_clinical_medicine_pocket_guide

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[] Medical notes_clinical_medicine_pocket_guide

  • 1.
  • 2. Contacts ‱ Phone/E-Mail Name Ph: e-mail: Name Ph: e-mail: Name Ph: e-mail: Name Ph: e-mail: Name Ph: e-mail: Name Ph: e-mail: Name Ph: e-mail: Name Ph: e-mail: Name Ph: e-mail: Name Ph: e-mail: Name Ph: e-mail: Name Ph: e-mail: FADevisM_FM.qxp 9/12/08 7:46 PM Page 2
  • 3. NotesClinical Medicine Pocket Guide Bruce Y. Lee, MD, MBA Purchase additional copies of this book at your health science bookstore or directly from F.A. Davis by shopping online at www.fadavis.com or by calling 800-323- 3555 (US) or 800-665-1148 (CAN) A Davis’s Notes Book F.A. DAVIS COMPANY ‱ Philadelphia Medical Notes FADevisM_FM.qxp 9/12/08 7:46 PM Page 3
  • 4. F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2009 by F. A. Davis Company All rights reserved. This product is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without writ- ten permission from the publisher. Printed in China by Imago Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Acquisitions Editor: Andy McPhee Developmental Editor: Yvonne Gillam Manager of Art and Design: Carolyn O’Brien Reviewers: Julie Z. Belcher, MD; Anna M. Choo, MD, JD; Carlos Duarte, MD; Brian G. Dwinnell, MD; Adam D. Elkin, MD; Sam Ghaffari, DO; Shilpa Grover, MD; Naghmeh Khodai, MD; Leslie H. Lee, MD; Elizabeth Mack, MD; John Tobias Musser, MD; Diane E. Nuñez, MS, ANP-C; Manali Indravadan Patel, MD, MPH; Mohammad Qasaymeh, MD; Susan D. Wolfsthal, MD; Erica Young, PA; and Kevan M. Zipin, MD As new scientiïŹc information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Authorization to photocopy items for internal or personal use, or the internal or per- sonal use of speciïŹc clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, pro- vided that the fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Dan- vers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-1746/09 Ï© $.25. FADevisM_FM.qxp 9/12/08 7:46 PM Page 4
  • 5. Place 27 ⁄8 Ï« 27 ⁄8 Sticky Notes here for a convenient and reïŹllable pad ✓ HIPAA Compliant ✓ OSHA Compliant Waterproof and Reusable Wipe-Free Pages Write directly onto any page of MD Notes with a ballpoint pen. Wipe old entries off with an alcohol pad and reuse. FADevisM_FM.qxp 9/12/08 7:46 PM Page 5
  • 6. Look for our other Davis’s Notes titles Coding Notes: Medical Insurance Pocket Guide ISBN-10: 0-8036-1536-1 / ISBN-13: 978-0-8036-1536-6 Derm Notes: Dermatology Clinical Pocket Guide ISBN-10: 0-8036-1495-0 / ISBN-13: 978-0-8036-1495-6 ECG Notes: Interpretation and Management Guide ISBN-10: 0-8036-1347-4 / ISBN-13: 978-0-8036-1347-8 LabNotes: Guide to Lab and Diagnostic Tests ISBN-10: 0-8036-1265-6 / ISBN-13: 978-0-8036-1265-5 NutriNotes: Nutrition & Diet Therapy Pocket Guide ISBN-10: 0-8036-1114-5 / ISBN-13: 978-0-8036-1114-6 MA Notes: Medical Assistant’s Pocket Guide ISBN-10: 0-8036-1281-8 / ISBN-13: 978-0-8036-1281-5 Neuro Notes: Clinical Pocket Guide ISBN-10: 0-8036-1747-X / ISBN-13: 978-0-8036-1747-6 Ortho Notes: Clinical Examination Pocket Guide ISBN-10: 0-8036-1350-4 / ISBN-13: 978-0-8036-1350-8 Provider’s Coding Notes: Billing & Coding Pocket Guide ISBN-10: 0-8036-1745-3 / ISBN-13: 978-0-8036-1745-2 PsychNotes: Clinical Pocket Guide ISBN-10: 0-8036-1286-9 / ISBN-13: 978-0-8036-1286-0 Rehab Notes: Evaluation and Intervention Pocket Guide ISBN-10: 0-8036-1398-9 /ISBN-13: 978-0-8036-1398-0 Respiratory Notes: Respiratory Therapist’s Guide ISBN-10: 0-8036-1467-5 / ISBN-13: 978-0-8036-1467-3 Screening Notes: Rehabilitation Specialists Pocket Guide ISBN-10: 0-8036-1573-6 /ISBN-13: 978-0-8036-1573-1 For a complete list of Davis’s Notes and other titles for health care providers, visit www.fadavis.com FADevisM_FM.qxp 9/12/08 7:46 PM Page 6
  • 7. Diseases and Disorders American Cancer Society Guidelines: Cancer (CA) Detection Breast CA (Women) ■ Ն40 y.o.: Mammogram every year ■ Clinical breast exam: 20-39 y.o. ~q3yr and Ն40 y.o. every year ■ Breast self-exam option for Ն20 y.o ■ ÏŸ20% lifetime risk: MRI and mammogram every year ■ 15%-20% lifetime risk: discuss w/physician about MRI Colon and Rectal CA ■ Ն50 y.o. male or female: Do one of following ïŹve: ■ Fecal occult blood test (FOBT) or fecal immunochemical test (FIT) every year ■ Flexible sigmoidoscopy q5yr ■ Yearly FOBT or FIT and ïŹ‚exible sigmoidoscopy q5yr (preferred) ■ Double-contrast barium enema q5yr ■ Colonoscopy q10yr ■ Start earlier (e.g., Ն40 y.o.) if: ■ Pt history of colorectal CA, adenomatous polyps, or chronic inïŹ‚ammatory bowel disease ■ Strong family history of colorectal CA or polyps (CA or polyps ïŹrst-degree relative Ïœ60 y.o. or two ïŹrst-degree relatives any age) ■ Family history of hereditary colorectal CA syndrome Cervical CA (for Women) ■ ~3 yr after begin vaginal intercourse or Ն21 y.o., whichever comes ïŹrst: Regular Papanicolaou (Pap) test every year or newer liquid-based Pap test q2yr ■ When Ն30 y.o.: ■ May continue every year or change to q3yr HPV DNA test and either conventional or liquid-based Pap test ■ If 3 normal Pap tests in a row, may change to q2-3yr ■ If risk factors*: Continue every year 1 BASICSBASICS *Prenatal DES exposure, HIV, or Ăžimmunity FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 1
  • 8. ■ Ն70 y.o.: If Ն3 normal Pap tests in row and no abnormal Pap last 10 years, may stop; if risk factors,* continue every year ■ Total hysterectomy (uterus and cervix): May stop, unless surgery was for cervical CA or pre-CA Endometrial (Uterine) CA (for Women) ■ High risk for hereditary nonpolyposis colon CA: Ն35 y.o.: offer endometrial biopsy every year Prostate CA (for Men) ■ Ն50 y.o.: Offer prostate-speciïŹc antigen and digital rectal examination every year ■ Ն45 y.o. high-risk (African-American or strong family history Ն1 ïŹrst-degree relatives [father, brothers] diagnosis Ïœ65 y.o.): Every year ■ Ն40 y.o. higher risk (multiple ïŹrst-degree relatives): Every year; if negative consider waiting until Ն45 y.o. Diagnostic and Therapuetic Procedures Electrocardiogram (ECG) Rate (Normal: 60–100 bpm) ■ Bradycardia: Ïœ60 bpm; tachycardia: ÏŸ100 bpm P Waves ■ Normal: P upright (positive), uniform, precedes each ORS ■ None: Rhythm junctional or ventricular ■ Right atrial enlargement (RAE): P ÏŸ2.5 mm tall in II and/or ÏŸ1.5 mm in V1; better criteria: (RVH or RV displacement signs) QR, Qr, qR, or qRs in V1 (w/o CAD); QRS in V1 Ïœ5 mm and ratio V2/V1 voltage ÏŸ6 ■ Left atrial enlargement (LAE): P duration ÏŸ0.12 sec in II; notched P in limb leads w/interpeak duration ÏŸ0.04 sec; terminal P negativity in V1 duration ÏŸ0.04 sec, depth ÏŸ1 mm ■ Biatrial enlargement (BAE): RAE and LAE, P in II ÏŸ2.5 mm tall and ÏŸ0.12 sec duration; initial and component of P in V1 ÏŸ1.5 mm tall and prominent P-terminal force 2 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 2
  • 9. PR Interval (Normal: 0.12–0.20 sec) ■ Short PR (Ïœ0.12 sec) Could be normal variant or: ■ Wolff-Parkinson-White (WPW): Accessory path RA†RV or LA†LV so early ventricle activation leads to Δ-wave (initial slurring of QRS), ⁄QRS duration (usu. ÏŸ0.10 sec), second- degree ST-T Δs from altered ventricular activation ■ Lown-Ganong-Levine: AV nodal bypass track into bundle of His † early ventricle activation w/o Δ-wave ■ AV junctional rhythms w/retrograde atrial activation (inverted P in II, III, aVF) ■ Ectopic atrial rhythms w/origin near AV node ■ Prolonged PR (:0.20 sec): ■ First-degree AV block (PR interval usu. constant); Ăžconduc- tion in atria, AV node, bundle of His, or bundle branch (when contralateral bundle blocked) ■ Second-degree AV block (PR interval normal or ⁄; some P waves do not conduct): Type I (Wenckebach): increasingly ⁄PR until a P not conducted; type II (Mobitz): ïŹxed PR intervals and nonconducted Ps ■ AV dissociation (Ps and QRS dissociated): Incomplete (slow SA node so subsidiary escape pacemaker takes over or subsidiary pacemaker faster than sinus rhythm) or complete (third-degree AV block: atria and ventricles each have separate pacemakers) QRS Complex ■ Poor R wave progression (PRWP): RՅ3 mm in V1–3, normal variant, LVH, LBBB, LAFB, anterior or anteroseptal MI, COPD (R/S ratio in V5–6 Ïœ1) ), diffuse inïŹltrative/myopathic processes, WPW pre-excitation, heart rotates clockwise, misplaced leads ■ Prominent anterior forces: R/S ratio ÏŸ1 in V1 or V2; normal variant, posterior MI, RBBB, WPW pre-excite QRS Interval (Normal: 0.6–0.10 sec) ■ QRS duration 0.10–0.12 sec: Incomplete RBBB or LBBB (same as complete RBBB and LBBB except QRS duration), nonspeciïŹc IVCD, LAFB, or LPFB (some) 3 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 3
  • 10. ■ QRS duration ÏŸ0.12 sec: ■ Complete RBBB: RV depolarizes after LV, second half QRS oriented right and anterior † terminal R’ in V1, terminal R in aVR, and downward ST-T in both V1/aVR; terminal S and upward ST-T in I, aVL, V6 ■ Complete LBBB: LV depolarizes after RV, second half QRS oriented left and posterior † terminal S and upward ST-T in V1; terminal R and downward ST-T in I, aVL, V6 ■ NonspeciïŹc Intraventricular Conduction DeïŹcit (IVCD): QRS duration ÏŸ0.10 sec but not bundle branch or fascicu- lar block criteria; causes: ventricular hypertrophy, MI, drugs (esp. class IA and IC antiarrhythmics), ⁄K+ ■ Ventricle-origin ectopic rhythm (e.g., VT) QT Interval (Normal: Ïœ1 ⁄2 R-R interval; normal QT Ïœ500 msec) ■ Beginning R wave † end of T wave; varies w/HR ■ Bazett’s formula: QTc = QT/͙RR (normal QTcՅ440 msec) ■ QTc ÏŸ0.47 sec (male) and ÏŸ0.48 sec (female) † long QT syn- drome (LQTS): (May † torsade de pointes: ventricular tachy- cardia w/varying QRS morphology): Drugs (e.g.,antiarrhyth- mics, tricyclics, phenothiazines); abnormal electrolytes (KÏ© , Ca2Ï© , Mg2Ï© ); Ăžthyroid, hypothermia, CNS dz (esp. SAH, CVA, trauma); hereditary LQTS; CAD (post-MI) Axis Deviation ■ Left-axis deviation (LAD): ■ LAFB: rS complexes in II, III, aVF; small Qs in I and/or aVL; R-peak time in aVL ÏŸ0.04 sec, often lurred R downstroke; QRS duration usu. Ïœ0.12 sec unless coexisting RBBB, usu. see poor R progression in V1–V3 and deeper S in V5 and V6, may mimic LVH voltage in aVL and mask LVH voltage in V5 and V6 ■ Other causes: LBBB, LVH, inferior MI, ⁄diaphragm ■ Right axis deviation (RAD): ■ LPFB: rS complex in lead I; qR in II, III, aVF, with R in III ÏŸR in II; QRS duration usu. Ïœ0.12 sec unless RBBB ■ Other causes: Cor pulmonale, pulmonary heart disease, pulmonary hypertension 4 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 4
  • 11. ST Segment ■ ST elevation ■ Normal variant “early repolarization” (usu. concave up, ending w/symmetrical, large, upright T waves) ■ Ischemic heart disease: Acute transmural injury (usu. convex up or straightened); persistent in post-acute MI suggests ventricular aneurysm ■ Prinzmetal’s (variant) angina (coronary vasospasm) ■ During exercise testing †⁄⁄⁄tight coronary artery stenosis or spasm (transmural ischemia) ■ Acute pericarditis: Concave up ⁄ST (not aVR); no reciprocal ĂžST (except in aVR); unlike “early repolarization”, usu. T low amplitude and ⁄HR; may see ĂžPR (atrial injury) ■ Other causes: LVH (in right precordial leads w/large S); LBBB; ⁄K+ ; hypothermia ■ ST Depression ■ Normal variants/artifacts: Pseudo ST depression (poor skin-electrode contact); physiologic J-junctional depression w/sinus tachycardia; hyperventilation ■ Ischemic heart disease: Subendocardial ischemia, non Q-wave MI, reciprocal Δs in acute Q-wave MI (e.g., ST depression in leads I and aVL with acute inferior MI) ■ Nonischemic causes: RVH (right precordial leads) or LVH (left precordial leads, I, aVL), digoxin, ĂžK+ , MVP (some), CNS dz, second-degree to IVCD (e.g., WPW, BBB) T Wave ■ Normal: T same direction as QRS except in V2; asymmetric w/ïŹrst half moving more slowly than second half; T always upright in I, II, V3–6, and always inverted in aVR ■ T-wave inversions: Normal variant, myocardial ischemia or infarction or contusion, pericarditis (subacute or old), myocarditis, CNS dz †⁄QT (esp. SAH), idiopathic apical hypertrophy, MVP, abnormal electrolytes, O2, CO2, pH, or temperature, digoxin, post-tachycardia or -pacing, RVH and LVH w/”strain” 5 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 5
  • 12. U Waves (Normal: Same Polarity and Usually Ïœ1/3 Amplitude of T) ■ Normal: Asymmetric w/ascending limb move more rapidly than descending limb (opposite to normal T) ■ Prominent upright U: Sinus bradycardia, ĂžKÏ© , Quinidine and other type 1A antiarrhythmics, CNS dz (long QT), LVH, MVP, Ăžthyroid ■ Negative or “inverted” U: Ischemic heart dz, MI (in leads with pathologic Q waves), angina, coronary vasospasm (Prinzmetal’s angina) ■ Nonischemic causes: Some cases of LVH or RVH (usu. in leads with prominent R waves), LQTS Myocardial Infarction ■ Q-wave MI: Total coronary occlusion ■ Non Q-wave MI: Subtotal occlusion ■ More leads with MI changes (Q waves and ST elevation) † larger infarct size and worse prognosis 6 BASICSBASICS Evolution of Q-Wave MI Q* T ST Pre-MI Hyperacute ⁄Amplitude/width May ⁄ Transmural Injury ⁄⁄⁄ Necrosis Ï© Terminal inversion Less Necrosis/Fibrosis Ï© Inversion Fibrosis Ï© Upright *Pathologic: duration ÏŸ0.04 s or ÏŸ25% R-amplitude ■ Conditions resembling MI: WPW pre-excitation (negative Δ-wave ~ pathologic Qs); IHSS (mimic pathologic Qs); LVH (QS or PRWP in V1-3); RVH (tall R in V1 or V2); LBBB (QS or PRWP in V1-3); pneumothorax (no right precordial R); COPD/cor pulmonale (no R V1-3 and/or inferior Q and RAD); LAFB (Qs anterior chest leads); acute pericarditis (⁄ST); CNS dz (diffuse ST-T wave Δs) FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 6
  • 13. Atrial Arrythmias ■ Premature atrial complexes: Single or repetitive, unifocal or multifocal, ectopic P (P’) may hide in preceding ST-T; P’R interval nl/⁄; P’ may be nonconducted, conducted w/aberration (e.g., wide QRS), or conducted normal ■ Premature junctional complexes: Retrograde P appears before (PR usu. Ïœ0.12 sec), during, or after QRS ■ Atrial ïŹbrillation: Poorly deïŹned atrial activity; appearance may ~old saw; ventricular response = irregularly irregular unless AV block ■ Atrial ïŹ‚utter: Regular atrial activity w/”clean” sawtooth appear- ance in II, III, aVF, and usu. discrete ‘P’ in V1; atrial rate = 150- 450/min; AV conduction ratio may vary 2:1, 3:1, etc ■ Ectopic atrial tachycardia and rhythm: Ectopic, discrete, unifocal P’ w/atrial rate Ïœ250/min (Ïœ100 † rhythm); ectopic P' waves usu. precede QRS w/P'R interval ÏœRP' interval; ventricular response: 1:1 or varying AV block ■ Multifocal atrial tachycardia and rhythm: ՆThree different P morphologies in given lead; rate = 100-250/min (Ïœ100 † rhythm), varying P'R intervals; ventricles: irregularly irregular (i.e., often confused with atrial ïŹbrillation); may be intermittent ■ Paroxysmal supraventricular tachycardia: Different re-entry cicuits; sudden onset and stop; usu. narrow QRS (unless BBB or rate-related aberrant ventricular conduction); types: AV nodal re-entrant tachycardia, AV reciprocating tachycardia, sinoatrial re-entrant tachycardia ■ Junctional rhythms and tachycardias: ■ Junctional escape beats: Origin AV jxn; rate: 40-60 bpm ■ Junctional escape rhythm: Ն3 Junctional escapes; rate 40-60 bpm; may be AV dissociation or retrograde † atria ■ Accelerated junctional rhythm: Rate = 60-100 bpm ■ Nonparoxysmal junctional tachycardia: HR ÏŸ100 bpm Ventricular Arrythmias ■ Premature ventricular complexes (PVCs): May be unifocal, multifocal, or multiformed; may be isolated single events or couplets, triplets, or salvos (4-6 in row); may occur early in cycle (R-on-T), after T, or late in cycle (fuse w/next QRS = fusion beat) 7 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 7
  • 14. ■ Ventricular tachycardia (VT): Sustained (ÏŸ30 sec) vs. nonsus- tained; monomorphic vs. polymorphic vs. torsade-de-pointes (polymorphic associated w/LQTS; phasic variations QRS polarity; rate often ÏŸ200 bpm; may † VïŹb); AV dissociation vs. retrograde atrial capture; Consider wide complex tachycardia is VT if: AV dissociation, ⁄⁄⁄axis deviation, QRS morphology atypical for BBB, concordance (all precordial leads in same direction), regular rhythm (RR intervals equal, irregularly irregular rhythm suggests atrial ïŹbrillation Ï© aberration or Ï© WPW pre-excitation), QRS morphology ~pre- vious PVCs, very wide QRS complexes (ÏŸ0.16 sec), no RS V1-V6, beginning of R to nadir S ÏŸ0.1 sec in any RS lead Lumbar Puncture Indications ■ Dx CNS disease, administer CNS treatment or treat hydrocephalus Contraindications ■ ⁄Intracranial pressure (ICP); intracranial mass effect (r/o mass lesion: head CT when signs of ⁄ICP) ■ Bleeding dysfunction ■ Infection near site ■ Elderly: avoid fast and large volume withdrawals. Equipment ■ Skin preparation: sterile sponges, povidone-iodine swabs, and EtOH swabs ■ Mask, sterile ïŹeld (towels and drapes), and gloves ■ Local anesthetic, usu. lidocaine 1% plain ■ Syringe (3 mL) and needles (22-G Ï« 1.5”, 25-G Ï« 5/8”) ■ Spinal needles (both 18- and 20-G, 3” length) ■ Three-way stopcock, sterile collection tubes, and manometer ■ Gauze dressings and adhesive bandage Preparation ■ Sterile technique; skin preparation ■ Find L4-5 space (L4 at iliac crest level) 8 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 8
  • 15. ■ Local anesthesia: inïŹltrate skin (25-G needle), then Δ to 22-G needle and advance † inïŹltrate deeper tissue Patient Positioning ■ Lateral decubitus: (preferred): Lateral decubitus position at edge of bed, while maximally ïŹ‚exing knees (near chest), hips, and back (opens L3/L4 space) pt. shoulders and hips perpendicular to bed ■ Sitting: (easier for obese or spinal dz/deformity): Pt. sits at bed edge, leans over two pillows, ïŹ‚exes head Technique ■ Insert spinal needle into skin and slowly advance (keep per- pendicular to skin, hold w/two hands, keep stylet in place); feel “pop”; perforate ligamentum ïŹ‚avum; withdraw stylet, and look for CSF drainage ■ If no CSF and needle advanced Ïœ4 cm (in adult), advance 2 mm, remove stylet, and check for CSF drainage; repeat until get CSF or needle advanced ÏŸ4 cm (then withdraw and redirect needle) ■ Connect three-way stopcock, and attach manometer; measure opening pressure (normal 70-180 mm CSF) ■ Send ïŹ‚uid for studies; remove needle and dress wound; pt. remains supine Ն12 h (minimize headaches) Complications Brain herniation (⁄ ICP and mass), infection (meningitis or empyema), subdural hematoma (rapid withdrawal of large volume CSF), bloody tap, spinal epidural hematoma, headache, dry tap † needle may be too lateral or deep ■ For CSF interpretation see Labs Tab Cricothyroidotomy Indications ■ Emergent need for airway; airway obstruction above cricoid cartilage level, failed intubation, or laryngeal trauma, mass, or hematoma 9 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 9
  • 16. Contraindications ■ Subglottic airway obstruction ■ Intubation possible ■ Uncorrectable coagulopathy Equipment ■ Suction ■ Local anesthesia (e.g., 1% lidocaine and 1:100,000 epinephrine) ■ Scalpel (ideally, No. 15 blade) ■ Retractors (Army-Navy or large vein refractors) ■ Kelly clamps ■ Suture (2-0 or 3-0 silk, 4-0 vicryl) ■ Cuffed tracheostomy tubes (preferable) or No. 4 or 5 small, ïŹ‚exible endotracheal (ET) tubes. Preparation ■ Palpate and locate cricothyroid ligament: between cricoid and thyroid cartilages (~1.5 cm inferior to thyroid cartilage); neck strap muscles lateral to ligament Patient Positioning ■ Neck extended (unless cervical injury) Technique ■ Sterilely prepare and drape skin ■ If enough time, inïŹltrate entry site with lidocaine ■ Scalpel † 3 cm horizontal (Ăžrisk of thyroid or cricothyroid cartilage damage) or vertical (better in obese when cannot palpate cricothyroid membrane) incision over center of cricothyroid membrane ■ Gently spread subcutaneous tissue w/clamp † expose cricothyroid membrane; may need retractors to spread neck strap muscles laterally ■ Avoid blood vessels, use scalpel to cut horizontally through membrane; may widen incision with clamp ■ Insert tracheostomy tube or endotracheal tube ■ InïŹ‚ate tube cuff; suture or tie down tube ■ Ventilate w/Ambu bag ■ Δ to formal tracheostomy Յ1 week (or risk stenosis) Complications ■ Bleeding, subglottic/glottic stenosis, chondritis 10 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 10
  • 17. Endotracheal Intubation Indications ■ SigniïŹcant ⁄ CO2 or Ăž O2 from respiration ■ Protect airway or pulmonary toilet Contraindications ■ Only intubate if necessary ■ Inaccessible/damaged oral cavity/larynx † nasal intubation (if no coagulopathy, severe intranasal problems, basilar skull fracture, or CSF leak) ■ Cervical spine instability Equipment ■ Lubricant: Water-soluble 2% lidocaine jelly ■ Tape and skin adhesive ■ O2 and bag-valve-mask ventilation device (Ambu bag) ■ If available: O2 saturation monitor,in-line CO2 monitor ■ Suction apparatus, suction tubing, tips, catheters ■ Laryngoscope w/straight and/or curved blade ■ Endotracheal tubes; syringe (10 mL) † inïŹ‚ate cuff ■ Flexible metal stylet and Magill forceps ■ Anesthesia Recommended ET Parameters (for nasal: add 2 cm to each measurement) Pree- Neo- 1-2 4-6 8-12 Age mie nate 6 mo yr yr yr Adult ET Tube Diameter (cm) 2.5 3–3.5 3.5–4 4–5 5–5.5 6–7 7.5–8.5 Blade (cm) 0 0–1 1 1–2 2 2–3 4–5 Insert: Lips to Mid-Trachea (cm)† 10 11 11–12 12 Ï© (age/2) ©:~23 ÂȘ~21 11 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 11
  • 18. Preparation ■ Rapid-sequence intubation: IV sedative (etomidate) † sedated, then IV muscle relaxant (succinylcholine); may add sedative (fentanyl or morphine), lidocaine, and/or ⁄⁄-lasting paralytic (vecuronium) ■ Awake intubation: Topical anesthetic, mild sedative and analgesic; stomach should be empty ■ Test laryngoscope; monitor HR, BP, and SaO2 Patient Positioning ■ Extend head and ïŹ‚ex neck; if possible (i.e., no cervical spine problem), place foam material, “doughnut”, or folded towel under occiput Technique ■ Ventilate pt. w/bag-valve-mask; assess airway ■ Remove foreign bodies (e.g., dentures) ■ Assistant: Continuously push back anterolateral cricoid carti- lage rim with ïŹrst and second ïŹngers until tube is placed ■ Open laryngoscope; use dominant hand to open mouth and nondominant hand to insert laryngoscope blade into right (left if left-handed) side of mouth ■ Sweep blade to midline tongue base (sweep tongue to other side); blade tip should be in valleculae (curved blade) or below epiglottis (straight blade) 12 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 12
  • 19. ■ Lift laryngoscope handle straight upward and forward † expose vocal cord; avoid lips, teeth, and trap tongue; using dominant hand pass lubricated ET tube through right (left if left-handed) corner of mouth and advance tip through vocal cords (while looking) ■ Remove stylet when proximal cuff ends at cord level ■ Advance tube into trachea; inïŹ‚ate cuff (~15 mm Hg); check placement: symmetric chest expansion, breath sounds both lungs (no breath in stomach) ■ Attach in-line CO2 monitor: Check for ⁄O2 saturation and CO2 in exhaled air ■ Secure tube w/tape (upper lip and cheek or neck) ■ Check chest x-ray (tip should be 4 cm above carina) ■ Once tube in place, longer-term sedation (aerosol benzocaine [20%] † tongue and posterior pharynx, midazolam or thiopental, fentanyl or morphine) Complications ■ Tube in esophagus or right mainstem bronchus ■ Aspiration (may Ăžrisk w/antacids, H2-blockers, metoclopramide, head-up positioning) ■ Damage to lips, teeth, tongue, airway Pericardiocentesis Indications ■ Cardiac tamponade ■ ⁄ pericardial effusion † Ăžhemodynamics Contraindications ■ Coagulopathy/bleeding dysfunction ■ Skin infection over needle insertion site Equipment ■ Skin preparation supplies, sterile gloves, towels/drapes ■ Local anesthetic (1% or 2% lidocaine, 25-G needle, 3-mL syringe) ■ Pulse oximeter, ECG monitoring (V lead) ■ 16- to 18-G spinal needle and No. 11 blade ■ 20-mL syringe and sample tubes 13 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 13
  • 20. Preparation ■ Continuous ECG monitoring (30° semi-Fowler position pre- ferred); if V lead attached to pericardiocentesis needle † ⁄ sensitivity; an insulated wire with alligator clips at each end works well ■ Prepare skin; sterile technique; wear sterile gloves, mask, and gown; drape over xiphoid area ■ Local anesthesia (inïŹltrate skin 1%-2% lidocaine) Patient Positioning ■ Supine with thorax (i.e., head of bed) elevated 30-45 degrees Technique ■ Needle: Insert (2 cm below costal margin to left adjacent to xiphoid with blade) and direct (upward and posterior) at 45-degree angle for 4-5 cm; aim toward right (preferable) or left (⁄risk penetrate RV) scapular tip ■ Advance (aspirate continuously) needle until encounter ïŹ‚uid, check for cardiac pulsations, or ⁄ST on ECG. May feel needle enter cavity ■ Remove blood: (usu. 5-10 mL because most is clotted); if Ն20 mL, then probably in RV ■ If hemodynamics do not improve, then may need thoracotomy or local pericardial window excision ■ Send ïŹ‚uid for appropriate studies Complications Myocardial wall injury/penetration, myocardial infarction, pneu- mothorax, bowel perforation Arterial Line Indications ■ Hemodynamic monitoring ■ Arterial blood sampling ■ Frequent blood draws Contraindications ■ Infection or lesion at insertion point ■ Occlusion or thrombosis of artery 14 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 14
  • 21. ■ Uncorrectable coagulopathy ■ Systemic infection (use peripheral site) Equipment ■ Peripheral arterial line (with angiocatheter): Angiocatheter (20- or 22-G, 2” length) or arterial line kit, sterile scalpel ■ Femoral arterial line (Seldinger technique): Seldinger kit: needle (16-18 G), 10-mL syringe, guide wire, sterile scalpel, dilator, catheter ■ Skin preparation supplies ■ Local anesthetic (1%-2% lidocaine, 25-G needle, 3-mL syringe) ■ Sterile gloves, towels or drapes, dressing supplies ■ Heparinized saline (pressurized delivery system) ■ Blood gas syringe (for arterial blood sampling) ■ Another 5-mL syringe w/heparinized saline ■ Sutures ■ Arterial pressure monitoring equipment ■ Arm board w/terrycloth roll Preparation ■ Peripheral (radial): Nondominant hand: perform Allen test (compress radial and ulnar arteries † palm blanches; release ulnar artery and check reperfusion of palm; delay ÏŸ5 sec = abnl † choose another site) to conïŹrm collateral circulation ■ Use sterile technique; prepare and drape skin ■ Use lidocaine to inïŹltrate entry and suture points Patient Positioning ■ Peripheral: Usu. radial artery but can do dorsalis pedis; pt. seated and supine; immobilize wrist on arm board w/roll under wrist in slight dorsiïŹ‚exion ■ Femoral: Supine Technique Peripheral Arterial Line (Angiocatheter) ■ Locate pulse w/index ïŹnger of nondominant hand; small incision w/scalpel over entry site ■ Insert angiocatheter at 30°–45° to artery † bright pulsatile red blood freely † catheter; slowly advance catheter until ïŹ‚ow stops; withdraw slightly until blood pumps again; advance catheter over needle into vessel 15 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 15
  • 22. Femoral Arterial Line (Seldinger Technique) ■ Locate pulse and make small incision w/scalpel ■ Connect 10-mL syringe to needle and insert needle at 45° to artery while aspirating on syringe ■ Insert and withdraw (while aspirating) needle until bright red blood pumps into syringe † detach syringe and use ïŹnger to block off hub of needle ■ Push guidewire through needle (should be no resistance); remove needle over wire ■ Cut incision larger so dilator can enter ■ Use dilator over wire to expand hole, then remove ■ Apply gentle pressure if bleeding ■ Push catheter over wire through hole into artery ■ Remove wire; check for bright red pulsatile blood in catheter hub For Peripheral or Femoral Arterial Line ■ If no blood, remove catheter and retry insertion; if still no blood, try ïŹ‚ushing needle w/heparinized saline; if not successful third time, try another site; cap catheter ■ Suture catheter to skin; draw blood samples prn and attach manometer; sterile dressing Removal of Arterial Line ■ Wear gloves; remove sutures, then catheter ■ ConïŹrm removed catheter is intact ■ Firm pressure to entry site for 10 min (longer when large lumen or anticoagulation) ■ After bleeding stopped, apply pressure dressing ■ Next day: check blood ïŹ‚ow to extremity Complications ■ Vessel perforation or thrombosis; limb ischemia* ■ Dislodged or loose connections to line ■ Incorrent placement or malfunction of line ■ Air embolus* ■ Infection, suppurative thrombophlebitis, sepsis* ■ Bleeding (apply pressure/additional sutures) 16 BASICSBASICS *Remove line immediately FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 16
  • 23. Central Line Locations ■ Femoral vein: Easy access; far from airways and lungs, but area can be dirty and prevent pt. from walking ■ Internal jugular (IJ) vein: ĂžBleed risk, but poor landmarks and can puncture carotid artery ■ Subclavian vein: Comfortable; clear landmarks; but risk of pneumothorax or bleeding Indications ■ Hyperalimentation or long-term IV therapy ■ Give medications (e.g., vasoactive/inotropes, phlebitic) ■ Hemodialysis or rapid ïŹ‚uid administration ■ Intracardiac pacing ■ Central venous pressure monitoring Contraindications ■ Subclavian: ĂžPulmonary function (COPD, asthma), high levels of PEEP, coagulopathy, superior vena cava thrombosis, upper thoracic trauma ■ IJ: Tracheostomy, ⁄⁄⁄pulmonary secretions ■ Femoral: Vena caval compromise (clot, extrinsic compression, IVC ïŹlter), local infection, cardiac arrest or low ïŹ‚ow states, requirements for pt. mobility. Equipment ■ Central line kits are available ■ Skin preparation supplies (iodine, chlorhexidine, or EtOH) ■ Local anesthetic (1%-2% lidocaine, 25-G needle, 3-mL syringe) ■ Sterile gloves, dressings, towels or drapes ■ Supplies for Seldinger technique (or speciïŹc intravascular access kit) ■ Needle (16- to 18-G): For IJ lines, only insert needle 0.5-1.0” (ÏŸ1.5” may † pneumothorax); 10-mL syringe ■ Guidewire, scalpel, dilator, catheter ■ If the Seldinger technique is not used, a catheter-over-needle system may be used ■ Heparinized saline 17 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 17
  • 24. ■ Suture ■ Central venous pressure monitoring device ■ May need ultrasound if difïŹculty inserting Preparation ■ For both insertion and removal: Use sterile technique; sterile gown, hair cover, face mask/shield ■ Skin preparation; sterile drapes ■ Flush catheter w/saline ■ Liberally infuse area w/local anesthetic Patient Positioning ■ Femoral: Supine; stand on side of your dominant hand (right side of pt. if you are right-handed) ■ IJ: Supine; turn pt. head 45° away from insertion side; remove pillow from under pt. head and place pt. in Trendelenburg position ■ Subclavian: Trendelenburg position, remove pillow, towel roll between scapulae Insertion Points ■ Femoral vein: One ïŹnger breadth medial to artery and two ïŹn- ger breadths inferior to inguinal ligament; with bevel up and at 45°–60° above skin, insert needle parallel to vessel (steeper angle †þrisk of entering peritoneum; more medial insertion angle † less chance of needle entering femoral artery) ■ IJ: Lateral to carotid; Landmark: Apex of triangle (clavicle and two heads of sternocleidomastoid) OR between sternal notch and mastoid process; insert needle at 70° to skin, and aim for ipsilateral nipple ■ Subclavian: 2 cm inferior to junction of lateral third and medial two thirds of clavicle and 2 cm above suprasternal notch; ïŹnder needle may be too short to reach vein Needle Approach ■ Femoral vein: With bevel up and at 45°-60° above skin, insert needle parallel to vessel (steeper angle †þrisk of entering peritoneum; more medial insertion angle †þchance of enter- ing femoral artery) ■ IJ: Insert needle at 70° to skin and aim for ipsilateral nipple; aim lateral; if unsuccessful, withdraw and carefully go 18 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 18
  • 25. slightly medial; reassess landmarks; can use long (~3”) angiocatheter instead of regular needle ■ Subclavian: Insert needle bevel up; guide placement w/ nondominant hand: place index ïŹnger at sternal notch and thumb at clavicle; keep needle parallel to ïŹ‚oor and ïŹrst aim for clavicle; when hit clavicle, walk needle down (push on needle tip; do not push on syringe) until just below clavicle; then advance needle 4-5 cm; once ïŹnd vein, rotate needle 90° so that bevel faces caudally; if no blood, withdraw and redirect more cephalad Technique ■ Make sure you continuously aspirate while advancing or withdrawing needle ■ Using appropriate insertion point and approach, locate vein w/ïŹnder needle (optional w/femoral vein) ■ Aspirate venous blood w/ïŹnder needle, then insert large-bore needle at same site and at same angle; use nondominant hand to grab needle hub and lower needle to parallel vein and aspirate again to reconïŹrm ïŹ‚ow (may use transducer to conïŹrm venous blood); hold needle in place, remove syringe, and thread guidewire into needle; check for ectopy ■ Remove needle over guidewire and continue to hold wire w/gauze; do not let go of guidewire until removed ■ Make incision 3–4 mm (w/scalpel) through skin and fascia; push dilator 3–4 cm over guidewire to expand subcutaneous tissue ■ Thread catheter over guidewire ■ Advance catheter and remove guidewire ■ Aspirate blood and ïŹ‚ush each port ■ Suture line in place and consider spacer in small pt ■ STAT chest x-ray to r/o PTX and check line placement Removing Central Lines ■ If line tunneled/trapped, may have to remove under ïŹ‚uoroscopy ■ Place pt. in Trendelenburg position (reverse Trendenlenburg for femoral lines) and remove any pillows ■ Remove all bandages, gauze, and all suture material ■ Pt. should hum or Valsalva maneuver during line removal ■ Apply sterile dressing (gauze and occlusive dressing) 19 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 19
  • 26. Complications Nonplacement/misplacement/nonfunction of line, dislodged line, infection, suppurative thrombophlebitis, catheter-related sepsis, pneumothorax, catheter/guidewire embolism, air embolism, vessel thrombosis, central vein thrombosis, hemorrhage, arrhythmias, myocardial or central vein perforation, pericardial tamponade, infection, hematoma, subcutaneous emphysema or ïŹ‚uid inïŹltra- tion, arterial puncture/laceration, hemorrhage Swan-Ganz (SG) Catheters Indications ■ Acute heart failure or severe hypovolemia ■ Hemodynamic instability ■ Severe pulmonary disease ■ Sample blood and determine cardiac output Contraindications ■ Infection or lesion at entry point ■ Occlusion or thrombosis of desired vessel ■ Uncorrectable coagulopathy ■ Caution: systemic infection Equipment ■ Skin preparation (iodine, chlorhexidine, or EtOH) ■ Local anesthetic (1%–2% lidocaine, 25-G needle, 3-mL syringe) ■ Sterile gloves, towels or drapes, dressings ■ Seldinger supplies: Needle (16–18-G), syringe (10 mL), guide wire, scalpel, dilator, catheter ■ Catheter supplies: SG catheter, monitor, protective sheath, syringe (3 mL),heparinized saline ■ Sutures Preparation ■ Prepare and drape skin; sites: subclavian (preferred), internal jugular (preferred), or femoral veins ■ Local anesthesia: InïŹltrate skin entry site ■ SG catheter: Flush each lumen w/heparinized saline; check balloon (inïŹ‚ate w/1–1.5 mL air); attach pressure monitor and infusion ports 20 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 20
  • 27. ■ Keep catheter in protective plastic container until zeroing pro- cedure complete; remove catheter from plastic container and move tip w/wrist ïŹ‚ick † appropriate waveform (monitor screen) Patient Positioning ■ Subclavian or IJ: Supine and 15° Trendelenburg’s position; turn pt.’s head away from entry site; place roll under spine between shoulder blades ■ Femoral: Supine and ïŹ‚at Technique ■ Use sterile technique ■ Connect 10-mL syringe to needle; small incision w/scalpel; Seldinger technique: cannulate vessel w/needle, pass wire through needle into vessel (no resistance) and widen passage- way w/dilator; thread introducer over wire into incision ■ Remove wire and aspirate blood to conïŹrm placement ■ Flush w/normal saline or heparin solution ■ Tightly cap introducer; suture introducer to skin ■ Insert ïŹ‚ushed and zeroed SG catheter; another person needed to inïŹ‚ate/deïŹ‚ate balloon during placement ■ Thread catheter through sheath protector; move protector out of way to end of catheter ■ Watch pressure monitor while advancing catheter; when catheter tip clears introducer, inïŹ‚ate balloon † 1-1.5 mL; balloon ïŹ‚oats catheter w/blood ïŹ‚ow † RA and through heart; check for distinctive pressures ■ Further advance catheter † “wedge” balloon in PA 21 BASICSBASICS Right atrium Right ventricle Pulmonary artery Pulmonary capillary wedge pressure PressureinmmHg FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 21
  • 28. ■ When wedged, deïŹ‚ate balloon and conïŹrm return of pulsatile pulmonary artery pressures ■ ReinïŹ‚ate balloon and reconïŹrm wedge position ■ Record appropriate pressures ■ Pull protective sheath over catheter and attach to introducer; conïŹrm introducer well sutured and caps tight; chest x-ray to conïŹrm placement ■ Check every day for infection; Δ catheter over wire q3–7d If Catheter Does Not Place Easily ■ DeïŹ‚ate balloon, then pull catheter back and advance again; ïŹ‚ush catheter w/5-10 mL cold saline to stiffen; occasionally, ïŹ‚uoroscopy needed Removal ■ Wear gloves; pt. supine; deïŹ‚ate balloon ■ Slowly remove catheter; may leave introducer for venous access; clean entry site w/sterile soap ■ Remove sutures; remove IV lines from transducer; pt. holds breath while remove introducer; check that entire catheter removed ■ Firm pressure at entry point Ï« Ն10 min; if bleeding stops † occlusive dressing Ï« 24-48 hrs; culture catheter tip ■ Check site next day for infection or bleeding Complications See complications for central venous lines; in addition, may cause pulmonary artery perforation, pulmonary infarction, car- diac arrhythmias Thoracentesis Indications ■ Diagnostic: Most new effusions, unless clear clinical dx with no e/o pleural space infection ■ Therapeutic: Dyspnea from large pleural effusion; also may aid work-up of large effusion Contraindications ■ No absolute contraindications ■ May need platelets/factor replacement: e.g., platelets Ïœ50,000, PT/PTT ÏŸ 2 Ï« normal 22 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 22
  • 29. ■ Relative contraindication: Cellulitis or herpes zoster at needle puncture site ■ Caution: mechanical or manual ventilation Equipment ■ Sterile towel, gauze pads, dressing, drape w/fenestration ■ Basin for preparation solution ■ Syringe(s) (10-20 mL) ■ Needles (22- and 25-G) for inïŹltration ■ Povidone iodine ■ Local anesthetic (e.g., 1% lidocaine): 10 mL ■ Heparin: 1 mL ■ Atropine: Available at bedside (for vasovagal reaction) ■ Syringe (50- to 60-mL) for aspiration ■ Sterile drainage tubing ■ Three-way stopcock ■ Needle or needle catheter (depends on technique): Hypodermic needle (18–22-G, 1.5”–2”), over-the-needle catheter (16–20-G needle) or through-the-needle catheter (14–18-G needle) ■ Scalpel (needle catheter technique only) ■ Sterile specimen bowl or Vacutainer bottle ■ Analysis containers: Iced blood gas syringe, specimen tubes (red-top and purple-top), sterile transport media for culture or 10-mL sterile container, 5 red-top specimen tubes for cytology or 10- to 50-mL plain bottle Preparation ■ Start IV; draw serum protein and LDH ■ Pulse-oximetry monitoring; O2 as needed ■ Diagnostic: Premoisten 50– to 60-mL collection syringe with 1 mL heparin (100 U/mL) to prevent clotting ■ Sterile technique, prepare skin with antiseptic; place sterile towels/drape around site ■ Effusion height: Percussion and tactile fremitus Patient Positioning ■ Upright (preferred): Pt. sits erect on bed edge and extended arms rest on bedside table; large effusion † pt. leans forward slightly; insert needle posterior rib at least one interspace below top of effusion; midscapular or posterior axillary line y 23 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 23
  • 30. ■ Lateral decubitus: Effusion side down, back at bed edge; insert needle posterior axillary line ■ Supine: Head elevated; insert needle midaxillary; needle should not be lower than 8th intercostal space (ICS) Technique ■ Needle technique: (Diagnostic † only small volumes) simple 20- or 22-G needle ■ Needle catheter technique: Insert catheter over or through needle and leave in pleural space 1. Use 25-G needle and syringe w/5–10-mL anesthetic 2. Raise skin wheal at rib upper edge in midscapular or poste- rior axillary line 3. Δ 25-G † 3.75-cm 22-G needle (on anesthetic syringe) 4. Insert 22-G needle through wheal and inïŹltrate subcutaneous tissue, muscle, and rib periosteum 5. Advance needle 1-2 mm † aspirate subcutaneous tissue/muscle † inïŹltrate small amount anesthetic 6. Repeating step 5 † “walk” needle above rib’s superior edge and advance through ICS until † pleural space 7. Hold needle perpendicular to chest † avoid trauma to neurovascular bundle of adjacent rib 8. When enter pleural space (may feel “pop”), aspirate ïŹ‚uid to ensure pleural space reached 9. Withdraw needle (grasp with thumb and index ïŹnger) 10. No ïŹ‚uid † “dry tap” (i.e., missed area) 11. Air bubbles † enter lung parenchyma (too high) 12. Postprocedure chest x-ray Terminate Procedure When ■ Diagnostic: Removal 50-100 mL ïŹ‚uid ■ Therapeutic: Dyspnea relief or removal 1000 mL ïŹ‚uid ■ May remove larger volumes if monitor pleural pressures q200 mL for second liter and then q100 mL; terminate if pleural pressure ÏŸ -20 mm Hg ■ Aspirate air † suggests lung puncture or laceration, unless needle Ïœ 20-G (making pneumothorax unlikely) ■ Δ Sx: e.g., abdominal pain, ⁄SOB ■ Persistent cough 24 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 24
  • 31. Complications Pneumothorax, cough, infection, hemothorax, splenic rupture, abdominal hemorrhage, unilateral pulmonary edema, air embolism, retained catheter fragment Light’s Criteria (Pleural Fluid = Exudate) 1) Pleural ïŹ‚uid:serum protein ratio ÏŸ0.5; 2) Pleural ïŹ‚uid LDH ÏŸ2/3 upper limit of normal serum LDH; 3) Pleural ïŹ‚uid:serum LDH ratio ÏŸ0.6 25 BASICSBASICS Special Pleural Fluid Assays Assay Diagnosis Suspected Amylase Pancreatitis, esophageal rupture Triglycerides Chylothorax, intrathoracic total parenteral nutrition Glucose Rheumatic effusion Urea or creatinine Urinothorax Cytology Malignancy Pleural Fluid Parapneumonic Empyema TB Malignant effusion PE/infarct Collagen vas- cular disease RA SLE Hemothorax Description Turbid Turbid, purulent Straw color, serosanguinous Turbid, bloody Straw color, bloody Turbid Green Yellow Bloody WBC Count ⁄ ⁄ Ïœ10,000 Ïœ10,000 ⁄ ⁄þ ⁄þ ⁄þ ⁄þ Main WBC PMNs PMNs Both Mono’s Both Both Both Both PMNs Glucose Ăž Ăž Ăž Ăž Serum ÞÞ Serum Serum pH ÏŸ7.3 Ïœ7.3 Ïœ7.4 Ïœ7.3 7.4 Ïœ7.3 ÏŸ7.3 Ïœ7.3 Diagnostic Features of Pleural Fluid FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 25
  • 32. Nasogastric and Feeding Tubes Indications Nasogastric Tubes ■ Diagnostic gastric lavage: Check for GI bleed ■ Decompress stomach: Ileus, GI obstruction, persistent vomit- ing, preabdominal surgery ■ Removal toxins and pill fragments ■ Heating or cooling (temperature abnormalities) ■ Prevent aspiration (e.g., trauma) ■ Deliver medications, feedings, contrast, or charcoal Feeding Tubes ■ Enteral feeding or medication delivery Contraindications ■ Facial fracture: (Use mouth instead) ■ Possible cervical spine injury (use extreme caution) ■ For feeding tube only: Adynamic ileus, malabsorptive syndromes, intestinal obstruction, gastroenteritis Equipment ■ 16-18 Fr nasogastric tube or feeding tube ■ Lubricant jelly (K-Y or lidocaine) ■ Topical anesthetic (e.g., Hurricane spray)* and nasal vasoconstrictors (e.g., phenylephrine)* ■ Emesis basin; cup of water and straw ■ Catheter tip syringe ■ Suction apparatus ■ Gloves and eye protection, stethoscope, tape, benzoin Preparation ■ Wear gloves and eyewear when place or remove tube ■ Estimate tube length = patient’s ear to umbilicus ■ Premedication: Spray anesthetic † throat back; apply vasoconstrictor and topical anesthetic † nasal mucosa ■ Liberally apply lubricant along tube/tube tip 26 BASICSBASICS *Optional FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 26
  • 33. Patient Positioning ■ Upright or decubitus, neck ïŹ‚exed Technique ■ Turn on suction apparatus (w/tonsil tip attached) ■ Pt. should hold emesis basin and cup of water ■ Insert tube in nostril toward occiput ■ Apply ïŹrm, constant pressure to tube while pt. takes small sips of water and swallows ■ Advance until two black lines on tube visible out of nares and nose between second and third black lines ■ Hold tube ïŹrmly in place close to nostril ■ Check placement in stomach: Attach catheter tip syringe to tube and inject 30-60 mL air; use stethoscope to hear air “whoosh” over epigastrium; use syringe to aspirate gastric ïŹ‚uid (normal pH Ïœ5) ■ Secure tube in two places (nose and second site like forehead or shoulder) w/benzoin and tape ■ Abdominal x-ray to conïŹrm placement (not necessary if suction applied) ■ Mark tube near nose to track proper placement ■ Record suction output volume and character For Feeding Tube Same procedure as nasogastric tube except: ■ Often need to place tube in duodenum or jejunem so: ■ Advance tube additional 20-40 cm ■ Pt. lays on right side for 8-12 hr ■ Fluid aspirate pH ÏŸ7 ■ May use metoclopramide or erythromycin to ⁄gastric motility † enhance tube passage ■ May need ïŹ‚uoroscopy to place ■ Do not use tube (or remove guidewire, if present) until check abdominal plain ïŹlm for placement Tube Removal ■ Disconnect tube from suction; remove tape ■ Pull steadily to remove tube; discard tube 27 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 27
  • 34. Complications ■ ⁄⁄⁄Gagging during placement: spray more topical anesthetic to back of throat ■ DifïŹculty passing tube † tube stuck in nose (try other nos- tril), coils in mouth or esophagus (use ice to chill/stiffen tube) ■ Placement in lung (coughing): Remove immediately ■ Hypovolemia from ⁄⁄⁄nasogastric tube output: IV ïŹ‚uids 0.5–1 mL LR or NS and 30 mEq KCI/L for every mL of output ■ If tube blockage, try any or all of following: ■ Check tube: Inject air into vent port and listen for hissing (which is normal) ■ Disconnect/reconnect apparatus or reposition tube ■ Irrigate tube w/30–40 mL NS ■ Throat discomfort: Throat lozenges prn ■ Aspiration pneumonia ■ Trauma to nasal mucosa, nares, sinus oriïŹces († sinusitis), lung, esophagus, gastric mucosa ■ Tube too low (NGT drains drain bile) ■ Tube too high (⁄aspiration risk) Paracentesis Indications ■ Therapeutic: Massive ascites †þ respiration, pain ■ Diagnostic: distinguish transudative vs exudative ascites ■ Dx spontaneous bacterial peritonitis, malignant, chylous Contraindications ■ Coagulopathy ■ Abdominal adhesions ■ Agitation ■ SigniïŹcantly distended bowel ■ Pregnancy ■ Infection (e.g., cellulitis at insertion site) Equipment ■ Paracentesis kits available ■ Skin preparation supplies 28 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 28
  • 35. ■ Local anesthetic (1%–2% lidocaine, 25-G needle, 3-mL syringe) ■ Sterile gloves, towels or drapes, and dressing ■ Spinal needle (20-G) ■ Syringe or vacuum bottle ■ Scalpel, #11 blade ■ ButterïŹ‚y needle (Ն20-G with sterile tubing) Preparation ■ Decompress bladder (void or urinary catheterization) ■ ID ïŹ‚ank region (gas-ïŹlled bowel will ïŹ‚oat to top); avoid previous incisions ■ Prepare skin; sterile technique; prepare and drape skin ■ Local anesthesia: InïŹltrate skin entry site, lower fascial levels and peritoneum ■ Ultrasound guidance: If previous abdominal surgery or infection Patient Positioning ■ Supine or sitting (leaning forward: better w/small amount of ïŹ‚uid); raise bed so pt. is comfortable Technique ■ Sterile technique ■ Insert and advance 20-G spinal needle w/stylet until feel peritoneum “give” ■ Remove stylet; attach syringe and advance needle (5-mm increments) while aspirate until get ïŹ‚uid ■ If remove large volume: Connect tubing btween spinal needle and (butterïŹ‚y needle) vacuum bottle; placing soft catheter (Seldinger technique) into peritoneal cavity may help ■ Remove needle and sterile dry dressing over site ■ Send ïŹ‚uid for appropriate tests Complications ■ Perforate organ or blood vesel, bleed/hematoma, persistent site leakage, infection, leaving catheter in abdominal cavity, hypotension, dilutional ĂžNaÏ© , hepatorenal syndrome 29 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 29
  • 36. Diagnostic Peritoneal Lavage (DPL) Indications ■ Acute abdominal trauma with coincident major nonabdominal injury (head injury, major fracture) ■ Critically ill pt. in whom an intra-abdominal source of fever or sepsis is suspected Contraindications ■ Multiple previous abdominal operations ■ Recent abdominal surgery, known abdominal adhesions, or obliteration of abdominal space from infection ■ Pregnancy ■ Caution: Dilated viscera (e.g., bowel loops) 30 BASICSBASICS Peritoneal Fluid Assays Assay Diagnosis Suspected Amylase Pancreatitic Triglycerides Chylous RBC count ÏŸ50.000/␟L Hemorrhagic ascites (malignancy, TB, or trauma) WBC ÏŸ350/␟L Infection (spontaneous bacterial peritonitis) PMNs Bacterial Mononuclear cells TB or fungal pHÏœ7 Infection Serum-Ascitic Albumin Gradient (SAAG) =AlbuminSerum–AlbuminAscites from same day High (Ն1.1 g/dL) Portal hypertension (transudative): CHF, cirrhosis, EtOH hepatitis, fulminant hepatic failure, portal-vein thrombosis Low (Ïœ1.1 g/dL) Exudative: Peritoneal carcinomatosis, pancreatic/biliary ascites, peritoneal TB, nephrotic syndrome, serositis, bowel obstruction/infarction FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 30
  • 37. Equipment ■ Skin preparation supplies (povidone-iodine solution) ■ Mask, sterile sponges, towels and drapes, gown, gloves ■ Local anesthetic, preferably 1% lidocaine w/1:100,000 epinephrine ■ Syringe (5- or 10-mL) ■ Needles (21-G Ï« 1.5” and 25-G Ï« 1/8”) ■ Sterile surgical tray, include scalpels (Nos. 11 and 15), scissors, Kelly clamps, pickups, needle holders ■ Sutures (0 silk, 2-0 silk, #1 and 4-0 vicryl, and 4-0 nylon) ■ Peritoneal catheter and connection tubing ■ Normal saline ■ Dressing supplies Preparation ■ Decompress stomach (nasogastric or orogastric tube) ■ Empty urinary bladder (void or Foley catheter) ■ Prepare and drape skin ■ Entry site: usu. just caudal to umbilicus; if pelvic fracture, supraumbilical ■ If not unconscious/sedated, local anesthesia to skin entry site, lower fascial levels, and peritoneum Patient Positioning ■ Supine or (if therapeutic) sitting Technique ■ Use sterile technique ■ Open technique described here. [Alternative: Seldinger technique (insert needle † abdomen, pass wire over needle, dilate, and pass catheter through tract)] ■ 5-mm vertical incision (No. 11 blade) down to linea alba fascia; do not enter abdominal cavity ■ Expose linea alba and place stay suture on each side of fascia (0 silk); hemostat † “tag” each suture ■ Make 1 cm vertical incision in linea alba; enter peritoneal cavity using blunt dissection; retract abdominal wall w/blunt end of Senn retractor ■ Insert and direct catheter (always keep perpendicular to abdominal wall) † right or left iliac region 31 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 31
  • 38. ■ Never force catheter against resistance ■ Gently aspirate ïŹ‚uid into syringe through catheter ■ Attach 1-L sterile saline bag to catheter and empty bag into peritoneal cavity by gravity ■ Drop bag to ground and allow ïŹ‚uid to siphon out ■ Send all ïŹ‚uid to laboratory; remove catheter ■ Suture incision closed (deep fascia: stay sutures of 0 silk; skin: 4-0 vicryl for subcuticular dermal closure and 4-0 nylon for skin closure) Complications ĂžSensitivity to retroperitoneal injury, ⁄sensitivity to minor intraperi- toneal injuries, false negative (poor technique or diaphragmatic injuries), wound infection, false positive (bleeding from incision), Ăžsensitivity from prior DPL (introduce gas/ïŹ‚uid into abdomen), bleeding, viscous perforation Transurethral Catheterization Indications ■ Urinary retention (e.g., neurogenic bladder) ■ Urinary sampling ■ Monitor urinary output ■ Bladder irrigation or tests (e.g., cystogram) Contraindications ■ Ureteral stricture or disruption ■ Acute urethral or prostatic infection ■ Relative: Anticoagulated pt. (use ⁄⁄⁄lubricants and nontraumatic technique) Equipment ■ Skin preparation supplies (povidone-iodine solution) ■ Sterile gloves, gauze, sponges, towels ■ Water-soluble lubricant (may use lidocaine 2% jelly) ■ Syringe (10-mL); sterile water or saline (5 mL) ■ Adhesive tape ■ Urinary drainage system w/tubing and collection bag ■ Urinary catheter (usually 16- or 18-Fr Foley): 32 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 32
  • 39. ■ Foley: Double-lumen (larger † urine, smaller † balloon inïŹ‚ation): Usu. used to drain bladder ■ Straight (red Robinson): Straight catheterization ■ Coude: DifïŹcult cases; narrow, curved, ïŹrmer tip ■ 3-way irrigation: Retrograde bladder irrigation Preparation ■ Pretest balloon inïŹ‚ation w/saline ■ Skin preparation: Sterile technique; retract foreskin (if pres- ent) or spread labia (urethral meatus anterior to vagina and posterior to clitoris); prepare entire penis or periurethral area (including urethral meatus) w/Ն3 povidone-iodine applica- tions; keep one hand sterile while other holds penile shaft ■ Always lubricate catheter tip and shaft ■ May inject lidocaine 2% into urethra preinsertion Patient Positioning ■ Supine; male: penis straight upward; female: frog-leg position Technique ■ Always use sterile technique; insert and slowly advance catheter through urethral meatus (male: maintain continuous upward penile traction; retract penis caudally may help pass prostatic urethra) Straight catheter Foley catheter 3-way irrigation catheter Coude catheter 33 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 33
  • 40. ■ Urine drains † inïŹ‚ate balloon (5 mL of saline); no urine † push on bladder; never inïŹ‚ate balloon w/o urinary return († damaged urethra) ■ Do not attempt multiple passes; if cannot avoid multiple passes, use smaller or Coude catheter placement ■ Gently pull back catheter until mild resistance ■ Tape catheter to thigh w/slight catheter slack ■ Return foreskin to back over penis head Complications DifïŹculty passing catheter (from any lower GU structure/disruption or prostatic enlargement); Traumatic catheterization † hematuria, transurethral tear/false passage; infection Suprapubic Catheterization Indications ■ Pelvic trauma causing urethral tear or disruption ■ Need for bladder drainage in the presence of urethral or prostate infection ■ Acute urinary retention when transurethral catheterization not possible Contraindications ■ Nonpalpable bladder ■ Uncorrectable bleeding diatheses Equipment ■ Skin preparation supplies (povidone-iodine solution) ■ Local anesthetic (1% lidocaine Ïź epinephrine; 22-G, 1.5” needle, 10-mL syringe) ■ Razor ■ Sterile gloves, mask, gauze sponges, towels and sheets ■ No. 11 scalpel ■ Syringe (60-mL) ■ Suprapubic catheter (usu. 14-G, 12”); intracatheter needle; needle holder, scissors, and pickups ■ Suture (2-0 silk or nylon) ■ Adhesive tape ■ Urinary drainage system w/bag and tubing ■ Sterile dressings 34 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 34
  • 41. Preparation ■ Local anesthetic agent Ïź IV sedation ■ Bladder must be distended and palpable ■ Shave umbilicus to pubis ■ Locate puncture site (midline, 4 cm above pubis) ■ Prepare skin w/alcohol solution ■ InïŹltrate skin, subcutaneous, abdominal wall, bladder wall w/local anesthetic ■ Prepare skin w/providone-iodine; sterile towels/drapes Patient Positioning ■ Supine w/roll under hips † extend abdomen and pelvis Technique ■ Always use sterile technique ■ Avoid multiple needle passes ■ Catheter-through-needle or sterile Seldinger technique ■ Shallow skin incision (No. 11 blade) ■ While aspirating, advance needle w/syringe through incision (at 60° to abdominal skin) until get urine ïŹ‚ow † syringe; remove syringe from needle ■ Thread intracath catheter through needle † bladder ■ Urine ïŹ‚ow in catheter † remove needle over catheter ■ Free ïŹ‚ow urine through catheter † suture catheter in place; attach urine collection device to catheter ■ Sterile dressing Complications DifïŹculty passing the suprapubic catheter, infection, traumatic placement, bowel perforation Arthrocentesis Indications ■ Dx septic joint or crystal-induced arthritis ■ Traumatic (blood in joint) vs inïŹ‚ammatory effusion ■ Dx intra-articular fracture (blood and fat globules) ■ Sx relief: Pain (hemarthrosis or tense effusion) ■ Give anti-inïŹ‚ammatory or local anesthetic medications 35 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 35
  • 42. Contraindications ■ Infection in tissue overlying puncture site ■ Bacteremia ■ Bleeding diatheses ■ Joint prosthesis Equipment ■ Skin preparation supplies and sterile gloves, drapes, basin, cup, test tubes, gauze, dressings, saline hemostat ■ Local anesthetic ■ Syringes (2, 10, and 20 mL); needles (18, 20, 22, and 25G) ■ Three-way stopcock ■ Green-top tube w/liquid anticoagulant, microscope slides w/coverslips, culture media (for infection) Preparation ■ Carefully identify landmarks and choose puncture site (avoid nerves, tendons, major vessels) ■ Sterile technique; prepare skin (allow betadine solution to dry btween applications); remove betadine w/EtOH to prevent betadine † joint space ■ Δ gloves after skin preparation; apply sterile towels/drape ■ InïŹltrate skin w/local anesthetic (22-/25-G needle) Patient Positioning ■ For knee lateral approach: Supine on examination table, feet at right angle, knee slightly ïŹ‚exed (15°–20°), rolled towel under popliteal space ■ For knee patella tendon approach: Pt. sits upright with foot perpendicular to ïŹ‚oor Technique ■ Attach (18- to 22-G) needle to syringe and insert through skin, subcutaneous tissue, and into joint space ■ Knee lateral approach: Insert needle 1 cm superior/lateral to superior lateral patella; may use hand to grasp and elevate patella slightly; needle † under patella at 45° to midjoint area; should be no resistance ■ Other approaches: Enter through patella tendon or medially or laterally directly above joint line 36 BASICSBASICS FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 36
  • 43. ■ Aspiration of synovial ïŹ‚uid conïŹrms joint space placement ■ If Δ syringe: Use hemostat to hold needle hub ■ Aspirate all joint space contents/ïŹ‚uid ■ Remove needle and dress wound; send ïŹ‚uid for tests ■ Larger effusions: Use larger syringe and consider using three-way stopcock (do not have to Δ syringe) Complications Infection, bleeding, anesthetic hypersensitivity. Fluid stops ïŹ‚owing (joint space drained, needle tip dislodged, or debris/clot obstruct tip), needle dislodged (slightly advance/retract needle, rotate bevel, or use Ăž pressure to aspirate), cartilage dam- age (from bouncing needle off bone) Abscess Incision and Drainage Indications ■ Palpable skin abscess (usu. ÏŸ5 mm) that does not resolve with conservative measures (warm soaks) 37 BASICSBASICS Monosodium urate (gout) Ca2Ï© pyrophosphate dihydrate (CPPD) Pseudogout Ca2Ï© phosphate (hydroxyapatite) Cholesterol Corticosteroids Strong negative birefringence, needle- shaped, long* Uricase digestion X-ray diffraction Weak and birefringence, rhomboid or small rods, pleomorphic* X-ray diffraction Not easily visualized* Electron microscopy X-ray diffraction Rhombic or platelike, notched corners, multicolor, occasionally small, needle- like* Chemical determination Pleomorphic; variable birefringence* Postintra-articular steroid Rx Joint Fluid Crystal Characteristics‡ Crystal Diagnosis *On polarizing microscope FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 37
  • 44. Contraindications ■ Very large abscesses (may need operating room) ■ Deep abscesses in very sensitive areas (supralevator, ischiorectal, perirectal) ■ Locations: Palmar space, deep plantar spaces, nasolabial folds (may drain to sphenoid sinus) Equipment ■ Universal precautions materials ■ Local anesthesia: 1% or 2% lidocaine with epinephrine, 10-cc syringe and 25-G needle 38 BASICSBASICS Joint Fluid Characteristics‡ WBC Mucin Δ Glucose* Dx Appears /mL3 PMNs Clot (mg/dL) Normal Clear, pale 0–200 Ïœ10% Good ~0 yellow Group I (noninïŹ‚ammatory) DJD; Clear to 50–4K Ïœ30% Good ~0 traumatic slight turbid arthritis Group II (noninfectious, mildly inïŹ‚ammatory) SLE; Clear to 0–9K Ïœ20% Good ~0 scleroderma slightly (occasion- turbid ally fair) Group III (noninfectious severe inïŹ‚ammatory) Gout Turbid 100–160K ~70% Poor 10 Pseudogout Turbid 50–75K ~70% Fair/poor ? RA Turbid 250–80K ~70% Poor 30 Group IV (infectious inïŹ‚ammatory effusions) Acute Very turbid 150–250K ~90% Poor 90 bacterial TB TB 2500–100K ~60% Poor 70 *Mean difference between synovial ïŹ‚uid and blood glucose ‡Adapted from Cohen, AS. Cecil’s Tectbook of Medicine FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 38
  • 45. 39 BASICSBASICS ■ Skin preparation solution and sterile drapes ■ No. 11 scalpel blade with handle ■ Sterile gauze and tape ■ Hemostat, scissors ■ Packing strip (plain or iodoform, 1/2”) ■ Culture swab Preparation ■ Universal precautions; prepare skin and sterile drapes ■ InïŹltrate local anesthetic, allow 2–3 minutes for anesthetic to take effect Patient Positioning ■ Depends on abscess location Technique ■ Cut through skin into abscess w/wide incision (No. 11 blade); incision should follow skin fold lines ■ Allow pus to drain; soak up w/gauzes ■ Swab inside abscess cavity (culture swab) ■ Gently explore cavity w/hemostat, break up loculations ■ Pack abscess cavity; dress wound w/gauze and tape ■ May send pus for Gram stain and culture (commonly strepto- coccus, staphylococcus, or enterics (perianal), or anaerobic and gram-negatives. Complications Abscess actually sebaceous cyst or hematoma, no drainage, bleeding FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 39
  • 46. 40 H&P Cranial Nerve Major Functions How to Test I Olfactory Smell Odor II Optic Vision Vision chart III Oculomotor Most eye muscles Follow ïŹnger IV Trochlear Superior oblique Look down at (eye Ăž and out) nose V Trigeminal Face sensation Touch face Chewing muscles Clench teeth VI Abducens Lateral rectus Look to side (eye lateral) VII Facial Face expressions Smile Tears/saliva ⁄þEyebrows Taste (anterior 2/3 Sugar or salt tongue) VIII Vestibuloco- Hearing Tuning fork chlear Equillibrium ? Vertigo (auditory) IX Glossopharyn- Taste (posterior Gag reïŹ‚ex geal 1/3 tongue) Swallow Sense carotid BP Uvula position X Vagus Larynx/pharynx ? Hoarseness Parasympathetic Open wide, say Taste “AH” XI Spinal Trapezius/ Shoulder Accessory sternocleidomastoid shrug/raise Turn head XII Hypoglossal Move tongue Tongue out FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 40
  • 47. 41 H&P Distinguishing Causes Upper Lower of Motor Motor Motor Extra- Defects Neuron Neuron Muscle Cerebellar pyramidal ĂžStrength Ï© Ï© Ï© ÏȘ ÏȘ Atrophy ÏȘ ⁄⁄⁄ ⁄ ÏȘ ÏȘ Fasciculations ÏȘ Ï© ÏȘ ÏȘ ÏȘ Babinski’s Ï© ÏȘ ÏȘ ÏȘ ÏȘ ⁄Tone Ï© ÏȘ ÏȘ ÏȘ ÏȘ ĂžTone ÏȘ Ï© Ï©/ÏȘ ÏȘ ÏȘ HyperreïŹ‚exia Ï© ÏȘ ÏȘ ÏȘ ÏȘ HyporeïŹ‚exia ÏȘ Ï© Ï©/ÏȘ ÏȘ ÏȘ Clasp knife Ï© ÏȘ ÏȘ ÏȘ ÏȘ Ataxia ÏȘ ÏȘ ÏȘ Ï© ÏȘ Distinguishing Vestibular (peripheral VIII nerve), Cerebellar, and Sensory (afferent pathway: peripheral nerve to thalamus/ parietal lobe) Lesions Finding Vestibular Cerebellar Sensory Vertigo Ï© Ïź ÏȘ Nystagmus Ï© Often Ï© ÏȘ Dysarthria ÏȘ Ïź ÏȘ Limb ataxia ÏȘ Usual Ï© Ï© Stand feet together; Ï© ÏȘ Ï© eyes open Stand feet together; Ăž ÏȘ ÏȘ eyes closed Vibratory and position sense Ï© Ï© Ăž Ankle reïŹ‚exes Ï© Ï© Ăž (continued) FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 41
  • 48. Lower Extremities Cannot toe walk when Ն50% loss S1 † gastrocnemius and anterior tibialis; cannot heel walk when Ն50% loss L4, L5 † tibialis anterior Sciatic Nerve Compression ■ Cross-leg (well leg) straight-raising test: Pt. lies supine and lifts uninvolved leg up with knee extended; positive: pain radiates posterior leg † foot ■ Straight leg-raising test: Like cross-leg but pt. lifts involved leg; positive: pain radiates back † below knee; hamstring problem: only posterior thigh pain Femoral Nerve Compression ■ Reverse leg-raising test: Pt. lies prone and extends involved leg with knee extended; if pain radiates anterior leg † foot, then femoral nerve compression Intrathecal Pathology ■ Milgram’s test: Pt. lies supine and raises legs ~5 cm and holds for 30 sec † stretches iliopsoas and anterior 42 H&P Distinguishing Causes Upper Lower of Motor Motor Motor Extra- Defects Neuron Neuron Muscle Cerebellar pyramidal Akinesia ÏȘ ÏȘ ÏȘ ÏȘ Ï©/ÏȘ Chorea or ÏȘ ÏȘ ÏȘ ÏȘ Ï©/ÏȘ athetosis Intention ÏȘ ÏȘ ÏȘ Ï©/ÏȘ ÏȘ tremor Resting tremor ÏȘ ÏȘ ÏȘ ÏȘ Ï©/ÏȘ FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 42
  • 49. 43 H&P abdominal muscles and ⁄ intrathecal pressure; if no leg pain, no intrathecal pathology ReïŹ‚exes Nerve ReïŹ‚ex Root Nerve Testing Jaw Pons Mandibular branch, trigeminal Tap mandible at down- ward angle w/mouth slightly open Biceps C5–6 Musculocu- taneous Tap biceps tendon w/arm ïŹ‚exed partially at elbow Brachiora- dialis C5–6 Radial Strike radius lower end just above wrist Normal: Elbow ïŹ‚exion Triceps C7–8 Radial Tap triceps tendon; support upper arm; let forearm hang Finger C8, T1 Median Either tap palm or hold pt.’s middle ïŹnger loosely and ïŹ‚ick ïŹngernail down † normal: ïŹnger slightly extends; abnormal: Hoffman’s sign (thumb ïŹ‚exes, adducts) Upper abdomen T7–10 Use blunt object to stroke abdomen lightly in and down Normal: Umbilicus deviates toward stimulus Lower abdomen T11–L1 (continued) FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 43
  • 50. 44 H&P Patellar L3–4 Femoral Strike patellar tendon Ankle (Achilles) S1–2 Tibial Tap Achilles tendon when pt. dorsiïŹ‚exes foot at ankle Normal: Plantar ïŹ‚exion Anal wink S2–4 Touch perianal skin Normal: Anus contracts Cremasteric reïŹ‚ex T12 Genital branch (gen- itofemoral) Stroke inner thigh Normal: Ipsilateral scrotal sac move ⁄ ReïŹ‚exes Nerve ReïŹ‚ex Root Nerve Testing FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 44
  • 51. 45 H&P Anterior thoracic rami Lateral thoracic rami Iliohypo- gastric Ilio- inguinal Obturator Lateral femoral cutaneous Anterior femoral cutaneous Medial femoral cutaneous Superficial peroneal Saphenous Sural Sural Tibial Lateral plantar Medial plantar Deep peroneal C2 C3 C4 C5 C6T1T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 C7 C8 S2 S3 Trigeminal Anterior cutaneous nerve neck Supraclavicular Axillary Lateral cutaneous nerve arm Median cutaneous nerve arm Lateral cutaneous nerve forearm Median cutaneous nerve forearm Radial Median Ulnar Saphenous Sole of foot Peripheral Nerves FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 45
  • 52. 46 H&P Sural Tibial Lateral plantar Medial plantar Saphenous Sole of foot Great occipital Lesser occipital Greater auricular Posterior rami of cervical nerves Axillary Supraclavicular Posterior cutaneous nerve forearm Lateral cutaneous nerve forearm Median cutaneous nerve arm Lateral thoracic rami Median cutaneous nerve forearm Radial Median Ulnar Posterior thoracic rami Posterior lumbar rami Posterior sacral rami Lateral femoral cutaneous Lateral femoral nerve of calf Superficial peroneal Sural Medial femoral cutaneous Calcaneal Saphenous Obturator C2 C3 C4 C5 C6 C7C8 T10 T12 L1 L2 L3 L4 L5 S3 S4 S5 S3 S4 S5 S1 S2 L2 L3 L4 L5 Peripheral Nerves FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 46
  • 53. 47 H&P Right Shoulder Liver Gallbladder Diaphragm Pancreas Cardiac Left Shoulder Lung Diaphragm (Kehr’s sign) Pancreas Cardiac Arm Cardiac Periumbilical Duodenum Appendix Suprapubic Bladder Uterus Groin/ Inner thigh Ureters Kidneys Jaw Cardiac Epigastric Duodenum Appendix Hiatal hernia Gallbladder and bile ducts Pancreas Referred Pain FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 47
  • 54. Brain Circulation 48 H&P Anterior communicating artery Communicating artery Middle cerebral artery Anterior cerebral artery Posterior cerebral artery Basilar artery Internal carotid Vertebral artery Superior cerebellar Anterior inferior cerebellar Posterior inferior cerebellar Anterior spinal FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 48
  • 55. Posterior cerebral Medial occipital and temporal cortex Posterior corpus callosum Upper midbrain Thalamus Superior cerebellar Upper cerebellum Upper pons Low midbrain Anterior inferior Upper cerebellum cerebellar Upper pons Low midbrain Posterior inferior Lower cerebellum cerebellar Medulla Anterior spinal (ASA) Anterior (ventral) spinal cord 49 H&P Main Artery Region of Brain Sustained Anterior cerebral Medial frontal and parietal Anterior corpus callosum Middle cerebral Lateral frontal, parietal, occipital, temporal cortex Lenticulostriate branches † caudate nucleus, putamen, upper internal capsule FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 49
  • 56. 50 H&P Frontal lobe problem solving, planning, apathy, inattention, aphasia, contralateral weakness, labile affect, Broca’s area Temporal lobe memory problems, aggressive sexual behavior Dominant: Wernicke’s aphasia Cerebellum ataxia, dysarthria, dysmetria, intention tremor, nystagmus, scanning speech Occipital lobe vision problems Parietal lobe contralateral sensation Dominant: reading, writing, or math ability Non-dominant: neglect, difficulty dressing Midbrain, Pons, Medulla CN 3–12 FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 50
  • 57. 51 H&P Macula Fovea Optic nerve Vitreous humor Optic disk Retina Sclera Conjuctiva Anterior chamber Cornea Pupil Iris Ciliary body Choroid Lens Zonule Optic nerve Left eye Left eye visual field Right eye visual field Right eye Optic chiasm Optic tract Optic radiation Striate cortex Lateral geniculate nucleus 1 1 3 3 2 2 4 4 5 5 Eye Examination FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 51
  • 58. 52 H&P Superior rectus CN3 Superior oblique CN4 Medial rectus CN3 Lateral rectus CN6 Inferior rectus CN3 Inferior oblique CN3 Optic nerve Macula Fovea Optic nerve (“blind spot”) Optic disk Blood vesselsOptic cup FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 52
  • 59. 53 H&P Weber’s test Rinne’s test Fork at midline forehead Bone conduction: Put fork on mastoid Normal: Sound Ï­ both ears Air conduction: Put fork near ear Abnormal: Sound lateralizes † Normal: Air conduction one ear † Ăžipsilateral conductive ÏŸ bone hearing or Ăžcontralateral Abnormal: Bone conduction sensorineural hearing ÏŸ air conduction, which results in Ăžconductive hearing Ear Examination Tuning Fork Tests Vertigo Dix-Hallpike test (Nylen-Barany test): Pt. sits on examination table and extends legs; turn pt.’s head 30°–45° to one side, and pt. quickly lies back so head hangs over table end; look for nystagmus; repeat whole procedure with head turned in opposite direction Positive: Nystagmus † benign paroxysmal positional vertigo FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 53
  • 60. 54 H&P Cardiac Manuevers Mechanism Maneuvers Right- Sided Murmurs Aortic Stenosis (AS) Mitral Regurgi- tation (MR) IHSS* Preload Venous return Inspiration, squatting, raise ⁄legs ⁄⁄ ⁄⁄ ÞÞ ÞÞ Expiration, Valsalva’s, standing, nitrates, diuretics ÞÞ ÞÞ ÞÞ ⁄⁄ Afterload Isometric hand grip ⁄⁄ ÞÞ ⁄⁄ ÞÞ ⁄⁄ Valsalva’s, vasodila- tors ÞÞ ÞÞ ÞÞ ⁄⁄þþ *IHSS Ï­ idiopathic hypertrophic subaortic stenosis FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 54
  • 61. 55 H&P Comments Diastole Early Mid Late Systole AS Heard best @ R base (radiate R carotid) AI Heard best @ 3rd/4th L ICS (if radiate R sternal border aortic root dilate, e.g., Marfan) MS MI TI VSD PDA MVP PS PI TS Early Mid Late Harsh Low Opening snap Rumble Opening snap Rumble Opening snap Systolic click Systolic click Blowing Blowing Second degree Machinery All MV murmurs heard best@ apex , S1. Can be confused with Austin Flint (AI: mid-diastolic murmur @ MV when blood enters from aorta & L atrium simultaneously; No OS) If LV volume (stand, Valsalva) earlier clicks, duration, intensity; if LV volume (squat, legs, hand grip) delay clicks, duration, intensity Radiate L axilla/back; severe MR S3; with isometric handgrip & stand squat Heard best @ 4th L sternal border; wide split S1; may with inspiration (Carvallo’s sign);TS often occurs with MS Heard best @ 4th L sternal border; may with inspiration (Carvallo’s sign); 1st degree rare; usually 2nd degree to pulm HTN Heard best @ L base; confused with venous hum; if pulmonary HTN, may disappear systolic murmur, pulmonic ejection sound Heard best @ L 3rd/4th ICS and along sternal border; NI S2 Heard best @ L 2nd ICS (radiate to L neck) + palpable thrill; wide split S2 Heard best @ L 2nd/3rd ICS; may during inspiration FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 55
  • 62. 56 H&P Heart Sound Causes S1 Soft: ĂžCardiac output, tachycardia, ⁄⁄⁄MR Loud: Hyperdynamic (fever, exercise), mitral stenosis, atrial myxoma S2 (Aortic) Soft: CalciïŹc AS Loud: Systemic hypertension (HTN), dilated aortic root S2 (Pulmonic) Loud: Pulmonary HTN S3 (Low frequency, ⁄Atrial pressure â€ â„ïŹ‚ow rates (congestive early diastole) heart failure [CHF] most common, valvular regurge, left † right shunts) Normal in age Ïœ40 yr Jugular Venous Pressure (JVP) S1 S2 A APP S1 S2 Type Causes Inspiration Expiration Normal or physiologic Wide, fixed, splitting Wide split, varies with inspiration Paradoxical splitting Intrathoracic pressure Atrial septal defect Pulmonary stenosis RBBB Hypertrophic cardiomyopathy A P A P A P P A A P PA Adapted from University of Washington Advanced Physical Diagnosis Learning and Teaching at the Bedside, Edition 1. S4 (Low-frequency Stiffened LV (HTN, AS, ischemic or presystolic portion hypertrophic cardiomyopathy, acute MR of diastole) from chorda tendinea rupture) FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 56
  • 63. 57 H&P 45° Right atrium Sternum Jugular vein a c v x y Maximal atrial filling Small and usually not visible TV opening and atrial emptying RV contraction and TV closure R atrial contraction ‱ Fluid overload ‱ Blockage before heart (SVC obstruction) ‱ CO (e.g., HR, constrictive pericarditis, R heart failure pericardial effusion, TS or TI, cardial tamponade) ‱ Hyperdynamic circulation JVP FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 57
  • 64. 58 H&P Sign Causes Kussmaul’s (during inspiration, Constrictive pericarditis JVP ⁄distention; Ăžin normal pt.) (negative in cardiac tamponade) Severe right heart failure Hepatojugular reïŹ‚ux (push Right ventricular failure if liver † ⁄venous return to right JVP remains elevated atrium) (transient only in normal pt.) Absent A waves Atrial ïŹbrillation Sinus tachycardia Dominant A waves Pulmonary HTN Pulmonary stenosis Tricuspid stenosis Right atrial myxoma Cannon A wave (very large Ventricular tachycardia A waves) Complete heart block Paroxysmal nodal tachycardia Dominant V wave Tricuspid regurgitation Absent X descent Atrial ïŹbrillation Exaggerated X descent Cardiac tamponade Constrictive pericarditis Large CV waves Tricuspid regurgitation Constrictive percarditis Sharp Y descent Constrictive pericarditis Tricuspid regurgitation Slow Y descent Right atrial myxoma Tricuspid stenosis Absent Y waves Cardiac tamponade Abdominal Examination FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 58
  • 65. 59 H&P RUQ Biliary colic Cholecystitis Duodenal ulcer Hepatitis RLL pneumonia LUQ Gastritis LLL pneumonia Pancreatitis Splenic problems Periumbilical Appendicitis Gastroenteritis Mesenteric lymphadenitis Myocardial ischemia or infarction Pancreatitis Back Acute pancreatitis Posterior duodenal ulcer Retrocecal appendicitis Ruptured AAA LLQ Diverticulitis Ectopic pregnancy Ovarian cyst Ovarian torsion Tubo-ovarian abscess RLQ Appendicitis Cecal diverticulitis Ectopic pregnancy Ovarian cyst Ovarian torsion Tubo-ovarian abscess Flank Abdominal aortic aneurysm Pylelonephritis Renal colic Suprapubic Ectopic pregnancy Endometriosis Mittelschmerz PID Ovarian cyst Uterine leiomyoma UTI McBurney’s point FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 59
  • 66. 60 H&P Abdominal Physical Examination Findings Appendicitis ■ Psoas’ sign: Place hand above pt.’s right knee; ask pt. to ïŹ‚ex right hip against resistance † pain ■ Obturator sign: Raise the pt.’s right leg with the knee ïŹ‚exed; rotate leg internally at hip ■ McBurney’s sign: Tenderness right abdomen two-thirds distance from anterior iliac spine to umbilicus ■ Rovsing’s sign: Palpate LLQ † RLQ pain Gallbladder Disorders ■ Murphy’s sign: In cholecystitis; pt. breathes out; palpate below right costal margin at midclavicular line; pt. inspires † gallbladder moves down, hits your hands; if gallbladder ten- der then pt. will stop inspiration † Ï© test; negative in chole- docholithiasis and ascending cholangitis ■ Charcot’s triad: In cholangitis; RUQ pain, fever, chills, jaundice Retroperitoneal Hemorrhage ■ Cullen’s sign: Bluish periumbilical discoloration ■ Grey Turner’s sign: Flank discoloration Vaginitis Candida Vulvovaginitis ■ Discharge: Dry cottage cheese–like ■ Symptoms: Vaginal/vulvar pruritus, irritation, burning, sore ■ Examination: Vulva: red, edema, and adherent white clumps Bacterial Vaginosis Amsel’s criteria (3 of 4 needed for diagnosis): ■ Discharge: Gray-white, thin, homogenous, adherent ■ Vaginal pH ÏŸ4.5 (normal pH: 3.8–4.5) ■ Clue cells: Bacteria-coated vaginal epithelial cells ■ Ï© Whiff (amine) test: KOH Ï© discharge † ïŹshy odor Trichomonas Vaginitis ■ Discharge: ⁄⁄⁄, grayish-green, frothy (CO2 bubbles) ■ Symptoms: Vulvar/vaginal pruritus, irritation, edema FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 60
  • 67. ■ Examination: strawberry cervix (punctate hemorrhage), pH ÏŸ5.0, Ï© whiff test, wet preparation (vaginal vault, not endocervix): Motile, ïŹ‚agellated trichomonads Atrophic Vaginitis ■ Discharge: Thin or clear ■ Symptoms: Vaginal irritation ■ Examination: Vagina/vulva: pale, dry, thin, ÞÞrugae, pH 5–7 Scrotal Complaints Epididymitis Ï­ Chlamydia, Gonorrhea, or E. coli ■ Insidious onset; dysuria, frequency, urethral discharge; swollen/tender upper posterior testicle ■ Rx: Antibiotics Torsion Ï­ Testis Twists on Spermatic Cord Axis ■ Surgical emergency: Sudden onset; abnormal testis elevation/ axis; “bell clapper” deformity (congenital unanchored swinging testis); absent cremasteric reïŹ‚ex and Prehn’s sign 61 H&P Spermatic cord Testicular veins Testicular artery Vas deferens Epididymis Testicle Hydrocele Torsion Varicocele Spermatocele Epididymitis FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 61
  • 68. Appendage Torsion Ï­ Twists on Testicular Appendage ■ Subacute symptoms, ïŹrm tender nodule upper pole epididymis; “blue dot sign” (blue/black spot visible beneath skin on testis/epididymis cranial aspect) ■ Rx: Bedrest and scrotal elevation Traumatic Injury Ï­ Epididymitis, Hematoma, or Rupture ■ Trauma history, ecchymosis, edema ■ Rx: Surgery if: uncertain diagnosis, ?testicle injury, disruption of tunica albuginea, or no ïŹ‚ow Doppler ultrasound Hydrocele Ï­ Fluid-Filled Sac Around Testis ■ Painless, ⁄size/tenseness from morning waking to later in day; transillumination: translucent ïŹ‚uid ■ Rx: Most resolve spontaneously; surgery if discomfort or tense hydrocele † testicle atrophy Varicocele Ï­ Abnormal Tortuous/Dilated Veins ■ Swelling, dull heaviness, ⁄ with exercise; no scrotal skin change; palpable “bag of worms” ■ Rx: May † infertility; scrotal support or surgery; ?obstructing mass if sudden onset in older pt. Spermatocele Ï­ Benign Cystic Sperm Accumulation ■ Asymptomatic: Painless, freely movable nodule superior to and separate from testis; transilluminates easily ■ Rx: None, unless bothersome 62 H&P FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 62
  • 71. Stages of Labor 65 H&P Cervical Comments Duration Dilation Contractions ⁄ frequency, Most 0–4 cm strength,and regularity; variable cervical thinning or hours to effacement days Most rapid cervical Average 4–10 cm dilation nulliparous: 5 hr; multiparous: 2 hr 1st Stage ActiveLatent May blend into active 15 min–3 hr 7–10 cm; phase; more rapid descent; slower baby passes lower into pace pelvis and deeper into birth canal; when no anesthesia, often vomiting and shaking Female actively pushes Nulliparous: Complete out baby 2–3 hr Nulliparous: ÏŸ1 cm/hr Multiparous: Multiparous: ÏŸ2 cm/hr Ïœ1 hr Accelerated by Ïœ1–30 min breastfeeding (release oxytocin) or pitocin 2ndStage (birth) Transition (Deceleration) 3rdStage (placenta delivery) FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 65
  • 72. 66 H&P Placenta Umbilical cord Uterus Cervix Blood Placenta abruptia More common when mother has high blood pressure or uses cocaine Placenta previa Usually in multiparous women or uterine structural abnormalities (e.g., fibroids) Placenta prematurely detaches (incompletely or completely) Placenta implants over or near cervix FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 66
  • 73. 67 H&P x The cephalic or vertex presentation (normal) Usually normal vaginal delivery Seated or full breech position Usually normal vaginal delivery The transverse position (rare) Usually shoulder first to present; usually cesarean section required Frank breech position ‱ Vertical or longitudinal lie ‱ Vertical or longitudinal lie ‱ Vertical or longitudinal lie ‱ Legs pointed straight upward ‱ Limbs to chest ‱ Neck flexed Front Front Back Back FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 67
  • 74. 68 H&P Frontal bone Frontal bone Parietal bone Parietal bone Occipital bone Lambdoidal suture Sagittal suture Coronal suture Metopic suture Anterior fontanelle (closes at age 18–24 months, may bulge with crying or ICP) Posterior fontanelle (closes at 2 months) Back Front Obstetric Visits and Testing Timeline FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 68
  • 75. 69 H&P 010 162428323537 203040 HgB/HCT,bloodtype,Rhantibody screen,RPR/VDRL,rubellaAb,hep BsAg,UA,urineC&S,Pap(thin prep),wetprep,PPD,HIV,TSH, gonorrhea,chlamydia Sicklecell,Tay-Sachs,cysticfibrosis,VZV,geneticscreen,andurinetoxscreens 4regularcontractionsin20minutesor8regularcontractionsin60minuteswithPROM withprogressiveeffacement>80%andcervicaldilation>1cm Gonorrhea,chlamydia, groupBstrepcx InitialVisitLabs Uterussize Ultrasound Pretermlabor Biophysical profile Pregnancy- associated plasmaprotein TripleScreen: ␀-HCG,AFP, estradiol One-hour glucolatest Non-stresstest RhoGAM OBVisits Weeks Every4weeks Fetalhearttone withDoppler Fetal heart tone Fundalheight &toxemia signs Q2–4wksQ0.5–1wkQ1–2 General SymphysispubisMidpointSpubis/umbilicusUmbilicusSize(cm)=Weekofgestation IfRh(–) Optional GestationalageFetalsurveyprn If>140&3hrwnl,thenrepeat @32wks Fetalmovement FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 69
  • 76. Skin Examination Lesion Descriptions ■ Macule: Flat; different color; can be seen, not felt ■ Excoriation: Mechanical skin erosion or destruction ■ LicheniïŹcation: Chronic irritation † leathery skin thickening with induration and hyperkeratosis ■ Onycholysis: Nail substance loosening or loss ■ Plaque: Flat, elevated, usu. ÏŸ5 mm ■ Solid raised, discrete: Papule (Յ5 mm), nodule (ÏŸ5 mm), pustule (pus-ïŹlled) ■ Blister: Fluid-ïŹlled vesicle (Յ5 mm), bulla (ÏŸ5 mm) Shoulder Examination Range of Motion (ROM) ■ Adhesive capsulitis (frozen shoulder): Stiffness, pain, and Ăžrange of movement; scar tissue forms post surgery or injury; develops when stop using joint from pain, injury, or chronic health condition (e.g., diabetes or arthritis) ■ Labral tears: Labrum Ï­ cartilage disk on glenoid; pain at back or in front on top of shoulder; feels deep inside; palpation does not duplicate pain; pain or “clunking” sound with overhead motion; causes: fall on outstretched arm, forceful lifting, or repetitive throwing Abduction/external rotation: Pt. places hand behind head and reaches as far down spine as possible; extent of reach should be at least ~C7 level; Forward ïŹ‚exion: Pt. traces out arc while reaching forward (elbow straight); should be able to move hand to a position over head; normal range 0–180° Extension: Ask pt. to reverse direction and trace an arc backward (elbow straight); pt. should be able to position hand behind back Appley scratch test (adduction and internal rotation): Ask pt. to place hand behind back and reach as high up spine as possible; note extent of reach relative to scapula/thoracic spine (should be at least T7); see ïŹgure for additional parts of examination 70 H&P FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 70
  • 78. 72 H&P Impingement (of Rotator Cuff Tendons) InïŹ‚ammation (tendonitis, bursitis), bone spurs, or â„ïŹ‚uid † squeez- ing rotator cuff (supraspinatus) tendon against bone (acromion); tendon may have tiny tears † scar tissue † further damage; night- time shoulder pain Neers’ test: Place your hand on pt. scapula; use other hand to hold pt. forearm; internally rotate pt. arm so that pt. thumb points downward; ïŹ‚ex pt. arm forward to position hand over head; pos- itive: pain Hawkin’s (for more subtle impingement): Raise pt. arm to 90° for- ward ïŹ‚exion; rotate it internally (i.e., thumb pointed down); puts humerus greater tubercle position to further compromise space beneath acromion; positive: pain FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 72
  • 79. 73 H&P - Biceps Yergason’s test: Flex pt. elbow 90°; pt. resists while externally rotate arm; if pain in biceps tendon † positive test † biceps tendon injury Rotator Cuff Tear ■ “Rotator cuff” Ï­ four tendons Ï­ supraspinatus (most common injured), infraspinatus, subscapularis, teres minor; muscles originate from scapula † single tendon unit insert- ing on humerus greater tuberosity ■ Repetitive overhead work or sports activity (e.g., painting, swimmers) ■ Gradual or acute onset; pain, stiffness; difïŹculty reaching overhead or behind back; may be snapping sensation Gerber’s liftoff test (check subscapularis function): Pt. places hand behind back, with palm facing out; pt. lifts hand away from back; partial tear will limit movement or cause pain; complete tears prevent movement Drop arm test for supraspinatus tears: Fully abduct pt.’s arm so that hand is over head; have pt. slowly lower arm to side; if suprapinatus torn, at ~90° arm will seem to drop suddenly toward body “Empty can” test for supraspinatus weakness: With elbows extended, thumbs pointing downward, and arms abducted to 90° in forward ïŹ‚exion, pt. attempts to elevate arms against examiner resistance Acromioclavicular Joint Dysfunction Cross-arm test: Pt. raises arm to 90°, then actively abducts, attempting to touch opposite shoulder; pain suggests problem FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 73
  • 80. 74 H&P Glenohumeral Joint Instability “Giving way” feeling or periodic shoulder dislocation; cannot keep humeral head centered in glenoid socket; shoulder pain in throw- ing athletes; anterior glenohumeral joint pain and impingement Sulcus test: With arm extened and at rest at pt.’s side, exert downward traction on humerus, and watch for sulcus or depres- sion lateral/inferior to acromion ■ Apprehension tests: Put humeral head in imminent subluxation or dislocation † pt. shows fear ■ Crank (pt. sitting or standing) or fulcrum (pt. supine) test: Place arm in extreme abduction and external rotation, which may cause apprehension ■ Relocation test: Pt. supine. ■ First part (fulcrum test): Push humeral head forward ■ Second part: Push humeral head posteriorly † prevents anterior subluxation † negative apprehension test ■ Inferior apprehension test: Hold upper limb in abduction, with pt.’s forearm resting on your shoulder; exert downward pressure over humeral neck; if shoulder unstable, head will be pushed down and groove appears Knee Examination Anterior Cruciate Ligament (ACL) Anterior drawer: Flex knee ~80°; relax hamstrings; stabilize foot; leg in neutral rotation; pull proximal tibia forward to see anterior FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 74
  • 81. 75 H&P displacement; quantify displacement (mm), and grade end point: hard (anterior cruciate ligament [ACL] halts forward motion) or soft (no ACL) Lachman’s: Anterior drawer variant; ïŹ‚ex (15°–20°) and externally rotate (relax iliotibial [IT] band) knee; one hand holds inner calf, and other hand holds outer aspect distal thigh; pull tibia anteriorly Pivot shift: Slight distal traction on leg; apply valgus and internal rotation force to extended knee; (no ACL † tibia anteriorly sub- luxes on distal femur); ïŹ‚ex knee ÏŸ30° (IT band † extendor † ïŹ‚exor of knee and tibial anterolateral subluxation reduces) Posterior Cruciate Ligament (PCL) Tibial drop back test: Flex knee 80°; compare proximal tibial prominence to femoral condyles; PCL-deïŹcient knee † gravity subluxes knee posteriorly; normal knee: tibial plateau located approximately 1 cm anterior to femoral condyles Quadriceps active test: Starting position: ïŹ‚ex knee 80°, neutral rotation; apply counterpressure against ankle while pt. ïŹres quadriceps muscle (i.e., tries to straighten leg); quadriceps pulls anteriorly through the tibial tubercle to reduce any posterior FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 75
  • 82. translation in the knee; if PCL injured, then will see reduction of a posteriorly subluxed tibia with quadriceps contraction Posterior drawer test: Flex knee 80°, palpate hamstrings to ensure they are relaxed; stabilize foot and keep in neutral rotation; push tibia posteriorly; if PCL-deïŹcient knee Meniscus MacMurray’s test: Place thumb and ïŹnger on joint line; watch face for pain; ïŹ‚ex leg, externally rotate foot, abduct and extend leg to test medial meniscal “clicks”; ïŹ‚ex leg, internally rotate and adduct for lateral meniscal “clicks” Squat test: During full squat, check joint line tenderness and rotate each leg internally (test lateral meniscus) and externally (test medial mensiscus) 76 H&P FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 76
  • 83. 77 H&P Patella Bulge test: Check for effusion; press down patella † empty suprapatellar pouch; wipe hand along medial side to displace ïŹ‚uid laterally; compress lateral side, and watch for bulge medially Effusion: tap test: Push sharply on patella; if effusion, patella will bounce off femur Patellar tilt test: With knee ïŹ‚exed 20°, use thumb to ïŹ‚ip up lateral edge of patella; normally can tilt patella up above hori- zontal; excessively tight lateral retinaculum † no upward movement Soloman’s test: Lift patella away from femur; synovial thickening † patella hard to grasp Patellar compression test: Attempts to correlate anterior knee pain w/articular degeneration; compress patella down into trochlear groove as pt. ïŹ‚exes and extends knee Lateral patellar apprehension test: Flex knee 45°; keep knee relaxed; use one hand to stabilize leg while using other hand to apply lateral pressure to patella Medial patellar apprehension test: Fully extend knee; apply medial translation force; medial subluxation, which most often occurs in a pt. after a lateral release, occurs in the initial ïŹ‚exion arc of 0°–30°; after this point, the patella reduces into the bony conïŹnes of the trochlear groove when the knee is ïŹ‚exed Patellar displacement (Sage sign): Normally can displace patella medially and laterally 25%–50% of patellar width; ⁄movement † loose patellar restraints (frequent in adolescent females) Suprapatellar plica snap test: Palpate medial suprapatellar plica midway between medial patellar border and adductor tubercle; roll plica under your ïŹngers while assessing pain/inïŹ‚ammation FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 77
  • 84. 78 H&P Upper and Lower Extremity Muscles Part Action Muscle Root Nerve Arm Externally Infraspinatus C5 Suprascapular rotate Abduct Supraspinatus Deltoid C5 Axillary Elbow Flex Biceps C5–6 Musculocuta- neous Brachioradialis Radial Extend Triceps C8 Radial Wrist Extend Extensor carpi C6–7 Radial radialis longus Extensor carpi C7 ulnaris Flexor carpi ulnaris C8 Ulnar Flex Flexor carpi radialis C6–7 Median Finger Extend Extensor digitorum C7 Radial 5th Abduct 1st dorsal T1 Ulnar Finger interosseous Abduct digiti minimi Thumb Abduct Abductor pollicis T1 Median brevis Oppose Opponens pollicis Median Hip Extend Gluteus maximus L5–S2 Inferior gluteal Flex Iliopsoas L2,L3 Femoral Abduct Gluteus medius and L4–S1 Superior minimus, tensor gluteal fasciae latae Thigh Abduct Abductors L2–4 Obturator FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 78
  • 85. 79 H&P Part Action Muscle Root Nerve Knee Extend Quadriceps femoris L3–4 Femoral Flex Hamstrings L5–S1 Sciatic Ankle Dorsi Tibialis anterior L4–5 Peroneal (ïŹ‚ex) Plantar Gastrocnemius S1–2 Tibial Soleus Foot Evert Peronei L5–S1 Peroneal Invert Tibialis posterior L4 Tibial Toes DorsiïŹ‚ex Extensor digitorum L5–S1 Peroneal longus Extensor digitorum S1 brevis FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 79
  • 86. 80 ALGOR Algorithms Hyperprolactinemia (Ïœ100 ng/mL) ■ Ectopic production ■ Breast stimulation (e.g., breastfeeding) ■ Δ metabolism (liver failure, renal failure) ■ Hypothyroidism ■ Medications (e.g., oral contraceptives, antipsychotics, antide- pressants, antihypertensives, H2-receptor blockers, opiates) Hyperprolactinemia (ÏŸ100 ng/mL) ■ Prolactin ■ Empty sella syndrome ■ Pituitary adenoma Normogonadotropic Hypogonadism (⁄⁄Androgens) ■ Polycystic ovary syndrome ■ Androgen-secreting tumor (ovarian or adrenal) ■ Cushing’s disease ■ Nonclassic congenital adrenal hyperplasia ■ Exogenous androgens ■ Thyroid disease ■ Acromegaly Uterine OutïŹ‚ow Obstruction ■ Asherman’s syndrome ■ Cervical stenosis Hypergonadotropic Hypogonadism (Ovarian Failure) ■ Postmenopausal ■ Premature failure: e.g., autoimmune, chemotherapy, galactosemia, genetic, 17-hydroxylase deïŹciency syndrome, mumps, pelvic radiation FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 80