Pediatric emergency medicine trisk 1082 1082
Bạn đang xem bản rút gọn của tài liệu. Xem và tải ngay bản đầy đủ của tài liệu tại đây (46.4 KB, 1 trang )
dullness to percussion suggests effusion. Unilateral absent/decreased breath
sounds are concerning for pneumothorax, pneumonia, foreign body aspiration, or
a pulmonary embolism however, the absence of decreased breath sounds does not
rule out these diagnoses. Crepitus of the neck or chest wall is indicative of
pneumomediastinum and/or pneumothorax. Tracheal deviation may be seen in
severe cases of tension pneumothorax where patients are in obvious distress.
If breath sounds are equal, yet there is an abnormal heart sound, then a cardiac
etiology is most likely. Pericardial disease can present with a friction rub, distant
heart sounds, neck vein distention, hypotension, impaired circulation, pulses
paradoxus, and chest pain worse in supine position and improved by leaning
forward. Signs of myocarditis include persistent tachycardia and orthostasis,
bradycardia, pulsus paradoxus, and a gallop rhythm. Physical examination
findings such as dyspnea, crackles, wheezes, gallop rhythms, neck vein
distention, and peripheral edema are seen in those with heart
failure/cardiomyopathy. There is a wide range of clinical presentations of children
with arrhythmias; they may be stable with irregular heart rates and rhythm or they
can present in cardiovascular shock. Signs of MI include rate and rhythm
disturbances, pallor, dyspnea, diaphoresis, as well as signs of heart failure.
Patients with a pulmonary embolism may present with a variety of physical
findings depending on the degree of arterial obstruction and thus hemodynamic
compromise (see Chapter 99 Pulmonary Emergencies ). Tachypnea, tachycardia,
decreased breath sounds, crackles, fever, a friction rub, an accentuated S2,
unexplained cyanosis, pleural friction rub, and/or cardiovascular collapse.
In addition to the usual cardiac and pulmonary examination, one should search
for “trigger points,” where palpation of the chest wall reproduces the pain
suggesting musculoskeletal inflammation. Reproduction of the pain by a
“hooking maneuver” performed over the lower anterior ribs implicates the
“slipping rib syndrome.” Pain following a dermatome unilaterally suggests
intercostal neuritis; children with zoster (shingles) may have pain preceding the
development of rash.
When focal, peripheral pain is found without a “trigger point,” the physician
should consider pain referred from areas of sensory nerve overlap. A relationship
of the pain to eating or swallowing suggests esophageal disease, and often, the
physical examination may appear normal. Some of these patients will have a thin
body habitus and/or cardiac findings of mitral valve prolapse.
Extrathoracic abnormalities, such as a rash or arthritis, may provide clues to
collagen disorders (see Chapter 101 Rheumatologic Emergencies ) or other
systemic illness. Marfan syndrome should be suspected in the tall thin patient
