Physical Examination and Laboratory Tests

Vital Signs

BP  125/80 (left arm, sitting); P  125 and regular; RR  28 and labored; T  98.5°F oral;

Weight  215 lb; Height  58; patient is appropriately anxious

Head, Eyes, Ears, Nose, and Throat

• Funduscopic examination normal
• Pharynx and nares clear
• Tympanic membranes intact

Skin

• Pale with cool extremities
• Slightly diaphoretic

Neck

• Neck supple with no bruits over carotid arteries
• No thyromegaly or adenopathy
• Positive JVD
• Positive HJR

Patient Case Question . What can you say about this patient’s blood pressure?

Patient Case Question . Why might this patient be tachycardic?

Patient Case Question . Why might this patient be tachypneic?

Patient Case Question . Is this patient technically underweight, overweight, obese, or is

her weight healthy?

Patient Case Question . Explain the pathophysiology of the abnormal skin

manifestations.

Patient Case Question . Do abnormal findings in the neck (JVD and HJR) suggest left

heart failure, right heart failure, or total CHF?

Lungs

• Bibasilar rales with auscultation
• Percussion was resonant throughout

Heart

• PMI displaced laterally
• Normal S1 and S2 with distinct S3 at apex
• No friction rubs or murmurs

Abdomen

• Soft to palpation with no bruits or masses
• Significant hepatomegaly and tenderness observed with deep palpation

Br

12 PART 1 ■ CARDIOVASCULAR DISORDERS

Extremities

• 2 pitting edema in feet and ankles extending bilaterally to mid-calf region
• Cool, sweaty skin
• Radial, dorsal pedis and posterior tibial pulses present and moderate in intensity

Neurological

• Alert and oriented  3 (to place, person, and time)
• Cranial and sensory nerves intact
• DTRs 2 and symmetric
• Strength is 3/5 throughout

Chest X-Ray

• Prominent cardiomegaly
• Perihilar shadows consistent with pulmonary edema

ECG

• Sinus tachycardia with waveform abnormalities consistent with LVH
• Pronounced Q waves consistent with previous myocardial infarction

ECHO

Cardiomegaly with poor left ventricular wall movement

Radionuclide Imaging

EF  39%

Patient Case Question . Which abnormal cardiac exam and chest x-ray findings closely

complement one another?

Patient Case Question . Which abnormal cardiac exam and ECG findings closely

complement one another?

Laboratory Blood Test Results

See Patient Case Table 3.1

Patient Case Table 3.1 Laboratory Blood Test Results

Na 153 meq/L PaCO2 53 mm Hg

K 3.2 meq/L PaO2 65 mm Hg (room air)

BUN 50 mg/dL WBC 5,100/mm3

Cr 2.3 mg/dL Hct 41%

Glu, fasting 131 mg/dL Hb 13.7 g/dL

Ca2 9.3 mg/dL Plt 220,000/mm3

Mg2 1.9 mg/dL Alb 3.5 g/dL

Alk phos 81 IU/L TSH 1.9 µU/mL

AST 45 IU/L T4 9.1 µg/dL

pH 7.35

CASE STUDY 3 ■ CONGESTIVE HEART FAILURE 13

Patient Case Question . What might the abnormal serum Na and K levels suggest?

Patient Case Question . Explain the abnormal BUN and serum Cr concentrations.

Patient Case Question . What might be causing the elevated serum glucose concentration?

Patient Case Question . Explain the abnormal serum AST level.

Patient Case Question  Explain the abnormal arterial blood gas findings.

Patient Case Question . Which of the hematologic findings, if any, are abnormal?

Patient Case Question . What do the TSH and T4 data suggest?

Patient Case Question  Identify four drugs that might be immediately helpful to this

patient.

Patient Case Question . Ejection fraction is an important cardiac function parameter

that is used to determine the contractile status of the heart and is measured with specialized testing procedures. If a pa