Dr. Huntley's
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The list of diagnostic tests mentioned in various sources as used in the diagnosis of Angina includes:
These home medical tests may be relevant to Angina:
Usually the doctor can diagnose angina by noting the symptoms and how they arise. However one or more diagnostic tests may be needed to exclude angina or to establish the severity of the underlying coronary disease. These include the electrocardiogram (ECG) at rest, the stress test, and x- rays of the coronary arteries (coronary "arteriogram" or "angiogram").
The ECG records electrical impulses of the heart. These may indicate that the heart muscle is not getting as much oxygen as it needs ("ischemia"); they may also indicate abnormalities in heart rhythm or some of the other possible abnormal features of the heart. To record the ECG, a technician positions a number of small contacts on the patient's arms, legs, and across the chest to connect them to an ECG machine.
For many patients with angina, the ECG at rest is normal. This is not surprising because the symptoms of angina occur during stress. Therefore, the functioning of the heart may be tested under stress, typically exercise. In the simplest stress test, the ECG is taken before, during, and after exercise to look for stress related abnormalities. Blood pressure is also measured during the stress test and symptoms are noted.
A more complex stress test involves picturing the blood flow pattern in the heart muscle during peak exercise and after rest. A tiny amount of a radioisotope, usually thallium, is injected into a vein at peak exercise and is taken up by normal heart muscle. A radioactivity detector and computer record the pattern of radioactivity distribution to various parts of the heart muscle. Regional differences in radioisotope concentration and in the rates at which the radioisotopes disappear are measures of unequal blood flow due to coronary artery narrowing, or due to failure of uptake in scarred heart muscle.
The most accurate way to assess the presence and severity of coronary disease is a coronary angiogram, an x-ray of the coronary artery. A long thin flexible tube (a "catheter") is threaded into an artery in the groin or forearm and advanced through the arterial system into one of the two major coronary arteries. A fluid that blocks x-rays (a "contrast medium" or "dye") is injected. X-rays of its distribution show the coronary arteries and their narrowing. (Source: excerpt from NHLBI, ANGINA: NHLBI)
Health care providers can usually find out if you have angina by listening to you talk about your symptoms and their patterns. They may also order some tests to further evaluate your angina. Tests may include x-rays; an electrocardiogram (ECG or EKG) at rest, and during and after exercise; a nuclear stress test; and coronary angiography. Variant angina can be diagnosed using a Holter monitor. Holter monitoring gets a non-stop reading of your heart rate and rhythm over a 24-hour period (or longer). You wear a recording device (the Holter monitor), which is connected to small metal disks called electrodes that are placed on your chest. With certain types of monitors, you can push a "record" button to capture a rhythm when you feel the symptoms of angina. (Source: excerpt from Angina: NWHIC)
The following medical news items are relevant to diagnosis of Angina:
16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the diagnostic tests for Angina.
All patients should have a CBC, sedimentation rate, chemistry panel, VDRL test, chest x-ray, and EKG. If there is sputum, a smear and culture should be done as soon as possible.
If a myocardial infarction is suspected, then serial EKGs and tests for the isoenzyme of creatine kinase (CK-MB) should be done if the initial EKG and enzymes do not show any significant changes. Serum cardiac troponin levels may also be diagnostic of a myocardial infarct. Thallium-201 scintigraphy is useful in diagnosing both myocardial infarction and coronary insufficiency. Exercise tolerance tests may help diagnose coronary insufficiency. Immediate coronary angiography should be undertaken if the condition deteriorates. This can be followed by immediate balloon angioplasty, reperfusion therapy, or bypass surgery.
If a pulmonary embolism is suspected, arterial blood gases and a ventilation-perfusion scan should be done. d -dimer testing of whole blood is a sensitive test of pulmonary embolus. Pulmonary angiography may need to be done if these are negative and pulmonary embolism is still strongly suspected.
If esophageal disease is suspected, an upper GI series with esophagogram should be done; this can be followed with esophagoscopy and gastroscopy if needed. A Bernstein test (acid perfusion of the esophagus) may reproduce the exact pain and distinguish esophageal reflux from a cardiac source of the pain. Ambulatory pH monitoring may also diagnose reflux esophagitis.
If pericarditis is suspected, echocardiography and possibly a CT scan of the chest and pericardium may be necessary. Coronary angiography may be necessary to diagnose coronary insufficiency. Echocardiography is also helpful in diagnosing mitral valve prolapse and the various myocardiopathies. Twenty-four-hr Holter monitoring is useful in diagnosing many causes of intermittent chest pain.
Referral to a cardiologist or pulmonologist may be appropriate at any point in this workup. Dissecting aneurysm may be confirmed by a CT scan or MRI of the chest.
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
If the patient reports arm pain after an injury, take a brief history of the injury from the patient. Then quickly assess him for severe injuries requiring immediate treatment. If you’ve ruled out severe injuries, check pulses, capillary refill time, sensation, and movement distal to the affected area because circulatory impairment or nerve injury may require immediate surgery. Inspect the arm for deformities, assess the level of pain, and immobilize the arm to prevent further injury.
If the patient reports continuous or intermittent arm pain, ask him to describe it and to relate when it began. Is the pain associated with repetitive or specific movements or positions? Ask him to point out other painful areas because arm pain may be referred. For example, arm pain commonly accompanies the characteristic chest pain of myocardial infarction, and right shoulder pain may be referred from the right upper quadrant abdominal pain of cholecystitis. Ask the patient if the pain worsens in the morning or in the evening, if it prevents him from performing his job, and if it restricts movement. Also ask if heat, rest, or drugs relieve it. Finally, ask about preexisting illnesses, a family history of gout or arthritis, and current drug therapy.
Next, perform a focused examination. Observe the way the patient walks, sits, and holds his arm. Inspect the entire arm, comparing it with the opposite arm for symmetry, movement, and muscle atrophy. (It’s important to know if the patient is right- or left-handed.) Palpate the entire arm for swelling, nodules, and tender areas. In both arms, compare active range of motion, muscle strength, and reflexes.
If the patient reports numbness or tingling, check his sensation to vibration, temperature, and pinprick. Compare bilateral hand grasps and shoulder strength to detect weakness.
If a patient has a cast, splint, or restrictive dressing, check for circulation, sensation, and mobility distal to the dressing. Ask the patient about edema and if the pain has worsened within the last 24 hours.
Examine the neck for pain on motion, point tenderness, muscle spasms, or arm pain when the neck is extended with the head toward the involved side. (See Arm pain: Common causes and associated findings.)
Source: Handbook of Signs & Symptoms (Third Edition), 2006
If the chest pain isn't severe, proceed with the history. Ask if the patient feels diffuse pain or can point to the painful area. Sometimes a patient won't perceive the sensation he's feeling as pain, so ask whether he has any discomfort radiating to his neck, jaw, arms, or back. If he does, ask him to describe it. Is it a dull, aching, pressurelike sensation? A sharp, stabbing, knifelike pain? Does he feel it on the surface or deep inside? Find out whether it's constant or intermittent. If it's intermittent, how long does it last? Ask if movement, exertion, breathing, position changes, or eating certain foods worsens or helps relieve the pain. Does anything in particular seem to bring it on?
Review the patient's history for cardiac or pulmonary disease, chest trauma, intestinal disease, or sickle cell anemia. Find out which medications he's taking, if any, and ask about recent dosage or schedule changes.
Take the patient's vital signs, noting tachypnea, fever, tachycardia, oxygen saturation, paradoxical pulse, and hypertension or hypotension. Also, look for jugular vein distention and peripheral edema. Observe the patient's breathing pattern, and inspect his chest for asymmetrical expansion. Auscultate his lungs for pleural friction rub, crackles, rhonchi, wheezing, or diminished or absent breath sounds. Next, auscultate for murmurs, clicks, gallops, or pericardial friction rub. Palpate for lifts, heaves, thrills, gallops, tactile fremitus, and abdominal masses or tenderness. (See Chest pain: Common causes and associated findings, pages 136 and 137.)
Source: Handbook of Signs & Symptoms (Third Edition), 2006
If the patient reports arm pain after an injury, take a brief history of the injury from the patient. Then quickly assess him for severe injuries requiring immediate treatment. If you’ve ruled out severe injuries, check pulses, capillary refill time, sensation, and movement distal to the affected area because circulatory impairment or nerve injury may require immediate surgery. Inspect the arm for deformities, assess the level of pain, and immobilize the arm to prevent further injury.
If the patient reports continuous or intermittent arm pain, ask him to describe it and to relate when it began. Is the pain associated with repetitive or specific movements or positions? Ask him to point out other painful areas because arm pain may be referred. For example, arm pain commonly accompanies the characteristic chest pain of myocardial infarction, and right shoulder pain may be referred from the right-upper-quadrant abdominal pain of cholecystitis. Ask the patient if the pain worsens in the morning or in the evening, if it prevents him from performing his job, and if it restricts any movements. Also ask if heat, rest, or drugs relieve it. Finally, ask about any preexisting illnesses, a family history of gout or arthritis, and current drug therapy.
Next, perform a focused examination. Observe the way the patient walks, sits, and holds his arm. Inspect the entire arm, comparing it with the opposite arm for symmetry, movement, and muscle atrophy. (It’s important to know if the patient is right- or left-handed.) Palpate the entire arm for swelling, nodules, and tender areas. In both arms, compare active range of motion, muscle strength, and reflexes.
If the patient reports numbness or tingling, check his sensation to vibration, temperature, and pinprick. Compare bilateral hand grasps and shoulder strength to detect weakness.
If the patient has a cast, splint, or restrictive dressing, check for circulation, sensation, and mobility distal to the dressing. Ask the patient about edema and if the pain has worsened within the last 24 hours.
Examine the neck for pain on motion, point tenderness, muscle spasms, or arm pain when the neck is extended with the head toward the involved side. (See Arm pain: Causes and associate findings.)
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
If the chest pain isn’t severe, proceed with the history. Ask if the patient feels diffuse pain or can point to the painful area. Sometimes a patient won’t perceive the sensation he’s feeling as pain, so ask whether he has any discomfort radiating to his neck, jaw, arms, or back. If he does, ask him to describe it. Is it a dull, aching, pressurelike sensation? A sharp, stabbing, knifelike pain? Does he feel it on the surface or deep inside? Find out whether it’s constant or intermittent. If it’s intermittent, how long does it last? Ask if movement, exertion, breathing, position changes, or eating certain foods worsens or helps relieve the pain. Does anything in particular seem to bring it on?
Review the patient’s history for cardiac or pulmonary disease, chest trauma, intestinal disease, or sickle cell anemia. Find out which medications he’s taking, if any, and ask about recent dosage or schedule changes.
Take the patient’s vital signs, noting tachypnea, fever, tachycardia, oxygen saturation, paradoxical pulse, and hypertension or hypotension. Also, look for jugular vein distention and peripheral edema. Observe the patient’s breathing pattern, and inspect his chest for asymmetrical expansion. Auscultate his lungs for pleural friction rub, crackles, rhonchi, wheezing, and diminished or absent breath sounds. Next, auscultate for murmurs, clicks, gallops, and pericardial friction rub. Palpate for lifts, heaves, thrills, gallops, tactile fremitus, and abdominal masses or tenderness. (See Chest pain: Causes and associated findings, pages 164 to 167.)
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
No reliable physical signs can be used to determine whether a patient with atypical chest pain has ischemic heart disease. The main purpose of the examination is to assess the patient for evidence of complications from atherosclerotic disease (e.g., peripheral vascular disease, cerebrovascular disease, and congestive heart failure). Pay attention to findings on the vascular examination (e.g., peripheral artery bruits, retinal arteriolar changes, the presence of a cardiac gallop) and for signs of the consequences of diminished myocardial contractility (e.g., lower extremity edema or pulmonary crackles) (Chapter 7.5).
A. Probability of IHD based on history. Prior to testing, the probability of IHD can be inferred by the estimates made by Diamond and Forrester (3). Examples of these estimates include (a) high probability situations (probability > 75%)—men aged more than 40 years and women aged more than
50 years with typical anginal symptoms; (b) moderate probability situations (probability > 50%)—men aged more than 40 years and women aged more than 60 years with atypical features; (c) low probability situations (probability < 20%)—men aged less than 40 years and women aged less than 50 with atypical features.
B. Response to nitroglycerin (NTG). Response of chest pain to sublingual NTG can be used (with caution) as an adjunct for determining whether a patient’s chest pain is from IHD. For example, a prompt response (< 3 minutes) increases the probability of IHD; however, it should be noted that esophageal spasm and biliary colic may also respond favorably to this intervention. Conversely, failure to respond to NTG should not be used to exclude the possibility of IHD.
C. Response to a gastrointestinal (GI) cocktail. It is common practice in many emergency room and urgent care settings to give a patient a GI cocktail that typically contains a liquid antacid, xylocaine, and an antispasmodic. No reliable studies exist on the diagnostic accuracy of this intervention.
D. Resting ECG. A normal resting ECG cannot be used as the sole criterion to rule out the presence of ischemic heart disease.
E. Exercise testing. The standard provocative test for patients with atypical chest pain who have at least a moderate risk for IHD is the exercise treadmill test. During exercise, the patient is monitored for symptoms of chest pain, heart rate, blood pressure response to exercise, arrhythmias, and ST-segment changes. A significant test includes an ST-segment depression of at least
1.0 mm below the baseline. It is important that the patient achieve a vigorous heart rate response to exercise. Approximately 20% of patients with an abnormal exercise tolerance test (ETT) have significant ST-segment changes occurring only at maximal or near-maximal heart rate changes. Therefore, when reviewing an ETT report, if the maximal heart rate achieved was less than 85% of the predicted heart rate, the results of the test should be interpreted more cautiously.
F. Other diagnostic tests. Some patients should not undergo the standard ETT for a number of reasons. These include the inability to exercise because of gait or instability problems and underlying ECG abnormalities that make the standard ETT unreadable (e.g., left ventricular hypertrophy with strain and left bundle branch block). If the patient is able to exercise, the preferred test will be either an exercise echocardiogram or an exercise thallium test. If the patient is unable to exercise, test options include a dobutamine echocardiogram and a dipyridamole (Persantine) thallium test. A divergence of opinion is seen as to which of these tests is best; however, each has higher sensitivity and specificity than the standard ETT.
The key to the diagnosis of atypical chest pain remains in the clinical history. An assessment of the probability of ischemic heart disease should be made on all patients. Those with a very low probability of IHD should not undergo diagnostic testing because, given the problems of sensitivity and specificity, the results will have little or no impact on the management of the patient. Critical pathways for triage have been proposed to help identify intermediate and high risk patients (4,5).
References
1. Panju AA, Hemmelgard BR, Guyatt GH, Simel DL. Is this patient having a myocardial infarction? JAMA 1998;280:1256–1263.
2. American College of Emergency Physicians. Clinical policy for the initial approach to adults presenting with a chief complaint of chest pain, with no history of trauma. Ann Emerg Med 1995;25:274–299.
3. Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med 1979;300:1350–1358.
4. Nichol G, Walls R, Goldman L, et al. A critical pathway for management of patients with acute chest pain who are at low risk for myocardial ischemia: recommendations and potential impact. Ann Intern Med 1997;127:996–1005.
5. Braunwald E, Mark DB, Jones RH. Diagnosing and managing unstable angina: quick reference guide for clinicians, Number 10. AHCPR Publication No.94-0603. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research and National Heart, Lung, and Blood Institute; 1994.>>>>
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
A. Focused physical examination. This should include vital signs (notably blood pressure). During a symptomatic episode, the finding of a mitral regurgitation murmur, S3 or S4 gallop, bruits or precordial lift all suggest a high likelihood of CAD. Findings of xanthelasma, tendinous xanthomata, tobacco-stained teeth and fingernails, and decreased or asymmetrical peripheral pulses indicate the likely presence of cardiac risk factors.
A. ECG. Despite the availability of a number of tests, the history remains very important in determining the likelihood of CAD in a patient with substernal chest pain. It is important to avoid using a normal ECG as “rule out” criteria, as many patients with unstable angina or even an acute MI may initially have a normal ECG. The diagnosis of CAD can be based on characteristic changes in the ST-T wave morphology during a symptomatic episode. Specifically, ST segment elevation greater than or equal to 1 mm in two or more consecutive leads is highly suggestive of an acute MI and is associated with the highest morbidity and mortality rate (3). ST segment depression of greater than or equal to 1 mm or T-wave inversion in two or more contiguous leads also strongly suggests ischemia or acute MI. The presence of Q waves greater than or equal to 0.04 seconds indicates previous MI. However, Q waves occurring in lead III alone may be a normal finding. As patients with initially normal ECG are still at risk for life-threatening complications and death (3% and 1%, respectively), it is important to follow serial ECGs for any evolution (3).
B. Creatinine kinase. The most widely used laboratory test for the detection of MI is the creatinine kinase enzyme. The isoenzyme, CK-MB, is abundant in the myocardium and, therefore, is sensitive and specific for myocardial injury. With acute MI, the MB fraction typically begins to rise within 6 hours of symptom onset, peaks at 18 hours, and falls after 24 hours. Total CK and CK-MB should be measured every 6 to 8 hours for a 24-hour period.
C. Troponin I and T. Both troponin I and T proteins are located on the contractile apparatus of the myocardium. These proteins are highly sensitive for myocardial injury. The prospective study conducted by Hamm et al. showed that in the 47 patients diagnosed with acute MI, 94% were positive for troponin T and 100% for troponin I (4). In addition, the negative predictive value of troponin T was 98.9% and that of troponin I was 99.7% (4).
D. Noninvasive and invasive testing. Both exercise and pharmacologic stress tests are used to assess for CAD in patients with stable angina. Unstable angina, uncontrolled hypertension, severe aortic stenosis, unstable arrythmias, and recent MI (4–6 weeks) are contraindications to stress testing.
1. Exercise ECG is a relatively inexpensive test with an overall sensitivity and specificity of 50% to 70%. It is most useful for those patients with a moderate pretest probability. Protocols are used to incrementally increase treadmill speed and elevation until the maximal heart rate for age is achieved. The ECG is monitored for ST depression and any ventricular arrythmias. The patient is also monitored for any fall in blood pressure or complaints of chest discomfort or dyspnea.
2. Exercise ECG with thallium or technetium sestamibi. The use of these radioisotopes improves the sensitivity and specificity of exercise ECG to approximately 90%. Thallium is distributed in proportion to blood flow. Areas of decreased uptake during exercise followed by normal uptake at rest suggest ischemia, whereas areas of persistent defect indicate infarction. Technetium is a newer agent with the advantage of a slow washout and added contrast, which results in fewer false-positive findings than thallium.
3. Exercise echocardiogram. This method detects wall motion abnormalities during exercise and has comparable sensitivity and specificity to exercise ECG. It is preferred in patients with abnormal resting ECGs and in patients with a low pretest probability. The disadvantages include difficulty imaging obese patients and the need to image as close to peak exercise as possible.
4. Dipyridamole or adenosine stress testing. The use of intravenous coronary vasodilators (dipyridamole or adenosine) in combination with a radioisotope (thallium or technetium sestamibi) is useful in patients who are unable to exercise. Areas of redistribution suggest ischemia, whereas areas of persistent defects indicate infarction. The use of phosphodiesterase inhibitors and the presence of reactive airway disease are contraindications.
5. Dobutamine echocardiogram. This method is also used for those who are unable to exercise. Dobutamine increases myocardial oxygen demand by increasing contractility and essentially “exercises” the heart. The echo monitors for any wall motion abnormalities.
6. Coronary angiography. Considered the “gold standard” test, this procedure provides the most detailed structural information of all the tests discussed. It is indicated in those patients who are at high risk for CAD by noninvasive tests and for those with persistent symptoms despite medical therapy. As diagnosis is closely tied to therapy, only those patients who are candidates for invasive procedures (e.g., percutaneous transluminal coronary angioplasty or coronary artery bypass graft) should be considered.
In patients presenting with substernal chest pain, the key to diagnosis involves quickly and accurately assessing for the likelihood of myocardial ischemia or infarction. An initial history, physical examination, and ECG will help in the risk assessment of the patient for significant CAD. Those who are at high to intermediate risk need to then be evaluated for presence of unstable angina. Once established, further steps involve the simultaneous evaluation with serial ECGs and enzymes along with therapy to reduce ischemia. Cardiac angiography is the final step in evaluation and treatment. For those at low risk for CAD and not meeting criteria for unstable angina, further evaluation involves noninvasive diagnostic testing with the possibility for cardiac angiography and revascularization.
References
1. Braunwald E, Mark DB, Jones RH. Unstable angina: diagnosis and management. Clinical Practice Guideline Number 10. AHCPR Publication No. 94-0602. Rockville, MD: Agency for Health Care Policy and Research and the National Heart, Lung, and Blood Institute, Public Health Service, US Department of Health and Human Services, March 1994.
2. Anderson KM, Wilson PWF, Odell PM. An updated coronary risk profile. A statement for health professionals. Circulation 1991;83:356–362.
3. Karlson BW, Hallgren HP, Liliequist JA. Emergency room prediction of mortality and severe complication in patients with suspected acute myocardial infarction. Eur Heart J 1994;15:1558–1565.
4. Hamm CW, Goldmann BU, Heeschen C. Emergency room triage of patients with acute chest pain by means of rapid testing for cardiac troponin T or troponin I.
N Engl J Med 1997;337:1648–1653.>
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
It is essential to maintain a high index of suspicion (low threshold for investigation) for critical problems; however, most chest pain has a benign cause. The patient with myocardial ischemia often is reluctant to label the symptom as “pain.” Instead descriptors are used such as squeezing, pressure, tightness, fullness, a heavy weight on the chest, burning (attributed to indigestion),
or a toothache (when jaw radiation is present). A closed fist held to the sternum is commonly employed to explain the symptoms. Pleuritic chest pain, intensified by a deep breath, usually has a pulmonary or chest wall origin. Recurrent episodic pain or persistent pain lasting days is unlikely to represent a critical problem. Pain lasting a few seconds or pain that is sharp or stabbing in quality is almost never ischemic, especially if reproducible by palpation
or movement.
Syncope with chest pain should raise suspicion of aortic dissection,
ruptured aortic aneurysm, pulmonary embolism, or critical aortic stenosis. “Angor anomie,” a sense of impending doom, is found in serious conditions such as myocardial infarction, pulmonary embolism, aortic dissection, and to a lesser extent, panic disorder. Sternal pain may be caused by xiphoidalgia, myelomatosis, ankylosing spondylitis, osteomyelitis, or traumatic fracture.
Source: Field Guide to Bedside Diagnosis, 2007
Pleuritic chest pain, intensified by a deep breath, usually has a pulmonary or chest wall origin. Cardiac pain is almost never pleuritic (LR 0.2), sharp or stabbing (LR 0.3), positional (LR 0.3) or reproduced by palpation (LR 0.3).
Source: Field Guide to Bedside Diagnosis, 2007
Perform a focused examination. Observe the way the patient walks, sits, and holds his arm. Inspect the entire arm, comparing it with the opposite arm for symmetry, movement, and muscle atrophy. (It’s important to know if the patient is right- or left-handed.) Palpate the entire arm for swelling, nodules, and tender areas. In both arms, compare active range of motion, muscle strength, and reflexes.
If the patient reports numbness or tingling, check his sensation to vibration, temperature, and pinprick. Compare bilateral hand grasps and shoulder strength to detect weakness.
If a patient has a cast, splint, or restrictive dressing, check for circulation, sensation, and mobility distal to the dressing. Ask the patient about edema and if the pain has worsened within the last 24 hours.
Examine the neck for pain on motion, point tenderness, muscle spasms, or arm pain when the neck is extended with the head toward the involved side.
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Take the patient’s vital signs, noting tachypnea, fever, tachycardia, oxygen saturation, paradoxical pulse, and hypertension or hypotension. Also, look for jugular vein distention and peripheral edema. Observe the patient’s breathing pattern, and inspect his chest for asymmetrical expansion. Auscultate his lungs for pleural friction rub, crackles, rhonchi, wheezing, or diminished or absent breath sounds. Next, auscultate for murmurs, clicks, gallops, or pericardial friction rub. Palpate for lifts, heaves, thrills, gallops, tactile fremitus, and abdominal masses or tenderness.
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
If the patient reports arm pain after an injury, take a brief history of the injury from the patient. Quickly assess him for severe injuries requiring immediate treatment. If you've ruled out severe injuries, check pulses, capillary refill time, sensation, and movement distal to the affected area because circulatory impairment or nerve injury may require immediate surgery. Inspect the arm for deformities, assess the level of pain, and immobilize the arm to prevent further injury.
If the patient reports continuous or intermittent arm pain, ask him to describe it and to relate when it began. Is the pain associated with repetitive or specific movements or positions? Ask him to point out other painful areas because arm pain may be referred. For example, arm pain commonly accompanies the characteristic chest pain of myocardial infarction, and right shoulder pain may be referred from the right upper quadrant abdominal pain of cholecystitis. Ask the patient if the pain worsens in the morning or in the evening, if it prevents him from performing his job, and if it restricts movement. Ask if heat, rest, or drugs relieve it. Finally, ask about preexisting illnesses, a family history of gout or arthritis, and current drug therapy.
Next, perform a focused examination. Observe the way the patient walks, sits, and holds his arm. Inspect the entire arm, comparing it with the opposite arm for symmetry, movement, and muscle atrophy. (It's important to know if the patient is right- or left-handed.) Palpate the entire arm for swelling, nodules, and tender areas. In both arms, compare active range of motion, muscle strength, and reflexes.
If the patient reports numbness or tingling, check his sensation to vibration, temperature, and pinprick. Compare bilateral hand grasps and shoulder strength to detect weakness.
If a patient has a cast, splint, or restrictive dressing, check for circulation, sensation, and mobility distal to the dressing. Ask the patient about edema and if the pain has worsened within the last 24 hours.
Examine the neck for pain on motion, point tenderness, muscle spasms, or arm pain when the neck is extended with the head toward the involved side.
Source: Nursing: Interpreting Signs and Symptoms, 2007
If the chest pain isn't severe, proceed with the history. Ask if the patient feels diffuse pain or can point to the painful area. Ask when the pain began and if the patient ever experienced this type of pain in the past. Sometimes a patient won't perceive the sensation he's feeling as pain, so ask whether he has any discomfort radiating to his neck, jaw, arms, or back. If he does, ask him to describe it. Is it a dull, aching, pressurelike sensation? A sharp, stabbing, knifelike pain? Does he feel it on the surface or deep inside? Ask him to rate the pain on a pain scale. Find out whether it's constant or intermittent. If it's intermittent, how long does it last? Ask if movement, exertion, breathing, position changes, or eating certain foods worsens or helps relieve the pain. Does anything in particular seem to bring it on?
Review the patient's history for cardiac or pulmonary disease, chest trauma, intestinal disease, or sickle cell anemia. Find out which medications he's taking, if any, and ask about recent dosage or schedule changes.
Take the patient's vital signs, noting tachypnea, fever, tachycardia, oxygen saturation, paradoxical pulse, and hypertension or hypotension. Place the patient on a cardiac monitor and evaluate his heart rhythm. Also, look for jugular vein distention and peripheral edema. Note the feel of his skin. Is it cool and clammy or warm and diaphoretic? Auscultate his chest for extra heart sounds. Observe the patient's breathing pattern, and inspect his chest for asymmetrical expansion. Auscultate his lungs for pleural friction rub, crackles, rhonchi, wheezing, or diminished or absent breath sounds. Next, auscultate for murmurs, clicks, gallops, or pericardial friction rub. Palpate for lifts, heaves, thrills, gallops, tactile fremitus, and abdominal masses or tenderness.
Source: Nursing: Interpreting Signs and Symptoms, 2007
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