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Identify hallmark signs identified from the physical exam and symptoms.
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The most common signs identified in the physical exam would be persistent respiratory infections (i.e., wheezing and coughing) noted during the examination. Pancreatic insufficiency (i.e., greasy, foul-smelling stools) was the main reason the patient was brought to the clinic. A Caucasian patient CF affects one in every 3,000 Caucasians (Katkin, 2017). Patients’ ages, as well as her patient’s small size for a five-month-old.
Cystic fibrosis is most common in the white population, affecting one in every 29 white people in the United States. Typically, the respiratory and digestive systems are the first to be affected. Respiratory symptoms include a persistent cough or wheeze, sputum production, recurrent or severe pneumonia, chronic sinusitis, and nasal polyps. “Infection persistence causes chronic local inflammation, airway damage, bronchiectasis, microabscess formation, and hemorrhagic pneumonia foci.”
I really appreciated how in the education section you mentioned to the mother what kind of symptoms would require immediate medical attention. This is not something that I thought about mentioning, but it is, of course, extremely important information! In my
Identify hallmark signs identified from the physical exam and symptoms.
education part, I focused more on helping the mother feel better about the diagnosis and the long-term effects on her daughter. You did that, but you went a step further and that caught my eye! When a healthy child contracts the flu, it can be a scary time for any parent. But when that child has Cystic Fibrosis and the flu, it can be an actual life or death situation. The flu on it’s own could lead to a worsening in symptoms for the child, but that flu could develop into pneumonia leading to a marked decrease in lung function that could ultimately result in death (CFF, n.d.). I found an interesting study, however, of a patient with cystic fibrosis that seemed to present with flu, but it turned out to be a completely different and rare disease that is not usually associated with cystic fibrosis; Kawasaki Disease. So, this teaches us that we should never take the easy way and just assume, but “when the clinical course does not follow a typical pathway including persistent, high fever, alternate etiologies must be considered” (Osborne, Stillwell, Zemanick, & Dominguez, 2017). Thank you for your very informative post!
Auscultation and percussion of the chest, which were first used about 200 years ago, are considered crucial in the physical examination and are taught to every medical student.
Although chest x-ray results can be used to confirm physical examination findings, objective data on clinician accuracy and reproducibility of physical examination findings is sparse.
Surprisingly, neither the physical examination’s effectiveness in predicting lung disease nor its worth in discriminating between different pulmonary disorders has been thoroughly researched.
Furthermore, lecturers rarely emphasize how difficult it is to elicit physical indications from the chest.
With less time to evaluate patients and easy access to chest radiographs, physicians are questioning whether a complete lung evaluation is necessary when a lower respiratory illness is suspected.
Auscultation, formerly thought to be a refined art that guided diagnostic and therapeutic decisions, is now “done as a bedside ritual,” according to some.
Idiopathic pulmonary fibrosis, chronic obstructive pulmonary disease, congestive heart failure, and pneumonia have all been proven by computerized studies of lung sounds.
4 pneumonia patients showed coarse crackles, most of which were pan-inspiratory, which was different from the other situations.
Interobserver reliability and accuracy in diagnosing pneumonia simply based on physical examination (i.e., without prior knowledge of clinical history or radiologic abnormalities) have never been studied before, to our knowledge.
The lack of data on the utility of physical examination in detecting community-acquired pneumonia was verified in a recent assessment of the pulmonary clinical examination5.
We prospectively examined 52 patients with suspected lower respiratory infection using a variety of chest physical examination maneuvers to assess the accuracy of specific maneuvers in diagnosing pneumonia and to compare the interobserver reliability of different clinicians examining the same patient.
From 1990 through 1993, we gathered data on patients who visited the Veterans Affairs Puget Sound Health Care System in Seattle, Washington, for evaluation of symptoms of acute lower respiratory tract inflammation.
Patients were evaluated during triage on weekdays from 8 a.m. to 5 p.m. by emergency department nurses or a study coordinator who selected potential study cases.
Because there were no non–clinically indicated procedures or confidentiality issues, the study was excused from approval by our Human Subjects Committee; however, patients were given the opportunity to participate or decline enrollment.
An acute cough or worsening of a chronic cough, as well as an increased amount or darker color of sputum, were used as inclusion criteria.
The research coordinator entered current symptoms, other relevant aspects of the medical history, and chosen laboratory and microbiological data (including a complete blood cell count and sputum gram stain and culture, if performed) on an enrollment data form.
Patients were evaluated in order by at least two of three board-certified physicians.
A general internist (physician A, J.E.W. ), an infectious diseases subspecialist in the division of general internal medicine (physician B, B.A.L. ), and a pulmonary medicine and infectious diseases subspecialist (physician B, B.A.L.) were among the physicians (physician C, J.V.H.).
To improve consistency in detecting relevant physical abnormalities, each physician listened to a professionally made audiotape of lung sounds before enrolling patients.
Each patient received a thorough, standardized respiratory assessment from each physician.
The doctors didn’t know the patient’s medical history, vital signs, or radiological findings, so they couldn’t ask him questions.
The doctors did not have to evaluate the patients in a specific order.
They tried to evaluate the patients as quickly as possible, but there was no set time limit.
The time between the first and third physician’s examinations varied from around half an hour to four hours, depending on the availability of the doctors.
Crackles, rhonchi, wheezing, tactile fremitus, whispered pectoriloquy, bronchophony, egophony, and pleural friction rub were all evaluated in the sitting posture.
Auscultation, palpation, fingertip percussion, and auscultatory percussion (auscultation while percussing the patient’s sternum) were used as physical diagnostic procedures.
Crackles were also looked for in both the right and left lateral decubitus positions on the patients (LDPs).
Each doctor used his or her own stethoscope, which was standard.
The following are the definitions of lung results used in this study:
Rales (crackles) are explosive, discontinuous sounds that can occur during early or late inspiration; rales in the LDP are those heard in the dependent lung; coarse rales are low-pitched sounds; fine rales are high-pitched, “velcro-type” sounds.
Rhonchi are low-pitched, continuous sounds that occur during early inspiration and clear or decrease after coughing.
Wheezes are high-pitched, continuous hissing sounds that can happen during inspiration or expiration.
A unilateral increase in palpable vocal vibrations conveyed through the chest wall is known as vocal (or tactile) fremitus.
The patient recites the word “ninety-nine” while the examiner palpate the chest wall in this maneuver.
Bronchophony is a change in the intensity and clarity of the patient’s voice as heard through the stethoscope transthoracically.
Egophony is a severe form of bronchophony that is defined as a nasal or bleating quality of transmitted vocal sounds elicited when the patient mouths the letter E but it sounds like the letter A to the examiner.
Murmured pectoriloquy is the stethoscope’s unusually clear perception of the patient’s whispered words (e.g., ninety-nine).
Pleural friction rub is a creaky sound that has been described as “resembling rubbing oiled leather” and can occur at any time during the breathing cycle.
The physical examination was recorded on a data sheet (Figure 1) that included an assessment of the anatomical location of abnormal findings, confirmation that the examiner was truly blind to the patient’s diagnosis, and a determination of whether the physical examination was consistent with pneumonia.
All patients had chest radiographs taken (standard posterior-anterior and lateral views) and analyzed by a board-certified radiologist with a special interest in chest radiography (J.T.) who was not informed of the patient’s clinical findings.
The presence of a radiographic infiltration in the pulmonary parenchyma was defined as pneumonia; the infiltrate had to be present on any accessible remote chest x-ray films.
When the initial radiologic assessment was probable pneumonia, a second set of chest x-ray films was obtained within a few days.
Pneumonia was identified when further radiographs revealed the existence of lung consolidation.
The gold standard for determining the presence of pneumonia was radiographic interpretation.
If a physical discovery was present in the same general area as an infiltrate on chest x-ray film, it was judged correct.
A professional epidemiologist carried out the statistical analyses (E.J.B.).
The statistic, a chance-corrected measure of agreement, was used to test the reliability of pulmonary examination findings between pairs of observers.
The Simel approach was used to obtain 8 diagnostic likelihood ratios and 95 percent confidence intervals.
9 We were unable to generate confidence intervals for likelihood ratios of zero because no acceptable method was available.
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