Physical examination

Question

G/A- acute sick looking
V/S- BP-100/60mmhg
PR-94beat per minute
RR- 22 breaths per minute
To- 36.2oc
Weight- 46kg
HEENT- pale conjunctiva and non icteric sclera
Has active nasal bleeding bilaterally
Nasal speculum examination shows laceration and bleeding on the anterior septum of the nasal cavity
LGS- has no lymphadinopathy
Respiratory system-
Inspection
-symmetrical chest and move with respiration
-no use of accessory muscles on respiration
Palpation
-no tenderness
Percussion
-resonance chest
Auscultation
-clear chest & vesicular breath sound heard all over the chest
CVS-
INSPECTION
- Apical impulse 4cm lateral to mid sternum at 5thintercostals space
PALPATION
- Point of maximum impulse on the same point with apical impulse
PERCUSSION
-dullness on the area of maximum impulse
AUSCULTATION
- s1 & s2 well heard at the 5th and 2nd ICS respectively
- No murmur and gallop
Abdomen-
INSPECTION
-no scar and moves with respiration
AUSCULTATION-normo active bowel sound----22gurgle /minute
PALPATION-
Superficial palpation—no tenderness
Deep palpation—no tenderness
--no mass or organomegally
PERCUSSION- tympanic abdomen
-no fluid trill or shifting dullness
GUS
-no suprapubic tenderness
-no costovertebral angle tenderness
Musculoskeletal system
-no bone or joint deformity
-no edema and tenderness
Integumentary system
-no rash
-no palmar pallor

CNS
-GCS-15/15
-conscious and oriented for time place and person
-intact cranial nerve examination
Discussion question
1. Summarize the new information obtained from P/E
2. How do you correlate physical finding of the patient with his problem?
3. Discuss pathophysiology of nasal bleeding.

Answer 1

1. Summary of New Information Obtained from Physical Examination

• General Appearance: The patient looks acutely ill.
• Vital Signs:
  • Blood Pressure: 100/60 mmHg (potentially low).
  • Pulse Rate: 94 beats per minute (normal).
  • Respiratory Rate: 22 breaths per minute (slightly elevated).
  • Temperature: 36.2 °C (normal).
  • Weight: 46 kg.
• HEENT:
  • Pale conjunctiva (indicative of anemia).
  • Active nasal bleeding bilaterally with laceration and bleeding observed on the anterior septum.
• Lymphatic System: No lymphadenopathy noted.
• Respiratory System: Examination shows:
  • Symmetrical chest with no use of accessory muscles.
  • Clear and vesicular breath sounds, with no tenderness or abnormalities detected.
• Cardiovascular System (CVS):
  • Displacement of the apical impulse (could indicate cardiomyopathy or other underlying issues).
  • Dullness noted at the area of maximum impulse, but S1 and S2 heart sounds are normal with no murmurs.
• Abdomen:
  • No tenderness, masses, or organomegaly; normoactive bowel sounds observed.
  • Tympanic on percussion, no signs of fluid accumulation.
• Genitourinary System (GUS): No suprapubic or costovertebral angle tenderness.
• Musculoskeletal System: No deformities, edema, or tenderness present.
• Integumentary System: No rashes or palmar pallor noted.
• Central Nervous System (CNS):
  • Alert and oriented, GCS score of 15/15, and intact cranial nerve examination.

2. Correlation of Physical Findings with the Patient's Problems

The key findings from the physical examination correlate significantly with the patient's acute condition:

• Pale Conjunctiva: Suggestive of anemia, which could be due to blood loss from the nasal bleeding.
• Active Nasal Bleeding: Indicates a local injury or underlying coagulopathy. The laceration on the anterior septum points to a possible trauma or an irritative process.
• Vital Signs:
  • The blood pressure of 100/60 mmHg is on the lower side, raising concerns about potential hypovolemia or shock due to blood loss.
  • The respiratory rate of 22 breaths per minute could indicate compensatory mechanisms from possible blood loss and/or distress.
• Dullness in the Cardiovascular Exam: This finding, along with an apical impulse that deviates from normal location, could suggest potential pathologies such as cardiomyopathy or pericardial effusion despite no overt murmurs being present.
• Abdominal Findings: With absence of tenderness and active bowel sounds, immediate intra-abdominal issues appear unlikely, reducing the risk of intra-abdominal bleeding exacerbating the situation.

3. Pathophysiology of Nasal Bleeding

Nasal bleeding, or epistaxis, can occur due to various mechanisms:

1. Local Factors:

   • Trauma or Injury: Local lacerations, such as those seen in this patient, can directly damage the blood vessels in the nasal mucosa.
   • Dry Air: Dry environments can lead to loss of moisture in the nasal mucosa, causing it to crack and bleed.
   • Hypertension: Elevated blood pressure can exacerbate vulnerability to bleeding due to damage to small vessels.

2. Systemic Factors:

   • Coagulopathy: Conditions that affect clotting factors (such as liver disease, thrombocytopenia) can lead to prolonged or recurrent bleeding.
   • Anemia: In this case, the observed pallor could indicate anemia, possibly causing an increased bleeding tendency.
   • Infectious or Allergic Rhinitis: Inflammation of the nasal mucosa could lead to increased vascularity and fragility of blood vessels, resulting in bleeding.

3. Vascular Factors:

   • Rich Vascular Supply: The nasal cavity is highly vascularized, especially at the anterior septum (Kiesselbach's plexus), where a minor trauma can lead to significant bleeding.

Summary

The physical examination reveals important findings that align with the clinical picture of acute nasal bleeding. The findings of anemia, active bleeding, and vital signs suggest potential hemodynamic instability. The pathophysiology of nasal bleeding involves local injuries, systemic conditions affecting hemostasis, and the inherent vascular characteristics of the nasal mucosa.