Diagnostic Tests for Blue baby
Blue baby Tests: Book Excerpts
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Blue baby Diagnosis: Book Excerpts
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CYANOSIS:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
It is wise to order a cardiology consult at the outset. Arterial blood gases, EKG, chest x-ray, and pulmonary function studies will diagnose most cases that are due to pulmonary or cardiac causes. If there is a history of drug ingestion, the blood should be drawn for methemoglobin and sulfhemoglobin testing. If a pulmonary embolism is suspected, a ventilation-perfusion scan and pulmonary arteriography may need to be done. If a peripheral embolism is suspected, angiography of the vessel involved will be diagnostic. Sputum or nose and throat cultures will be useful in diagnosing the infectious diseases associated with cyanosis.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Cyanosis:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If cyanosis accompanies less-acute conditions, perform a thorough examination. Begin with a history, focusing on cardiac, pulmonary, and hematologic disorders. Ask about previous surgery. Then begin the physical examination by taking the patient's vital signs. Inspect the skin and mucous membranes to determine the extent of cyanosis. Ask the patient when he first noticed the cyanosis. Does it subside and recur? Is it aggravated by cold, smoking, or stress? Is it alleviated by massage or rewarming? Check the skin for coolness, pallor, redness, pain, and ulceration. Also note clubbing.
Next, evaluate the patient's level of consciousness. Ask about headaches, dizziness, or blurred vision. Then test his motor strength. Ask about pain in the arms and legs (especially with walking) and about abnormal sensations, such as numbness, tingling, and coldness.
Ask about chest pain and its severity. Can the patient identify aggravating and alleviating factors? Palpate peripheral pulses, and test the capillary refill time. Also, note edema. Auscultate heart rate and rhythm, especially noting gallops and murmurs. Also auscultate the abdominal aorta and femoral arteries to detect any bruits.
Does the patient have a cough? Is it productive? If so, have the patient describe the sputum. Evaluate his respiratory rate and rhythm. Check for nasal flaring and use of accessory muscles. Ask about sleep apnea. Does the patient sleep with his head propped up on pillows? Inspect the patient for asymmetrical chest expansion or barrel chest. Percuss the lungs for dullness or hyperresonance, and auscultate for decreased or adventitious breath sounds.
Inspect the abdomen for ascites, and test for shifting dullness or fluid wave. Percuss and palpate for liver enlargement and tenderness. Also, ask about nausea, anorexia, and weight loss.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Cyanosis:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If cyanosis accompanies less acute conditions, perform a thorough examination. Begin with a history, focusing on cardiac, pulmonary, and hematologic disorders. Ask about previous surgery. Then begin the physical examination by taking vital signs. Inspect the skin and mucous membranes to determine the extent of cyanosis. Ask the patient when he first noticed the cyanosis. Does it subside and recur? Is it aggravated by cold, smoking, or stress? Is it alleviated by massage or rewarming? Check the skin for coolness, pallor, redness, pain, and ulceration. Also note clubbing.
Next, evaluate the patient’s level of consciousness. Ask about headaches, dizziness, or blurred vision. Then test his motor strength. Ask about pain in the arms and legs (especially with walking) and about abnormal sensations, such as numbness, tingling, and coldness.
Ask about chest pain and its severity. Can the patient identify any aggravating or alleviating factors? Palpate peripheral pulses, and test capillary refill time. Also, check for edema. Auscultate heart rate and rhythm, especially noting gallops and murmurs. Also auscultate the abdominal aorta and femoral arteries to detect any bruits.
Does the patient have a cough? Is it productive? If so, have the patient describe the sputum. Evaluate respiratory rate and rhythm. Check for nasal flaring and use of accessory muscles. Ask about sleep apnea. Does the patient sleep with his head propped up on pillows? Inspect the patient for asymmetrical chest expansion or barrel chest. Percuss the lungs for dullness or hyperresonance, and auscultate for decreased or adventitious breath sounds.
Inspect the abdomen for ascites, and test for shifting dullness or a fluid wave. Percuss and palpate the abdomen for liver enlargement and tenderness. Also, ask about nausea, anorexia, and weight loss.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Cyanosis:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Initial assessment. Vital signs are very important: tachycardia suggests cardiac arrhythmia, shock, volume depletion, anemia, or fever (Chapter 7.12). An increased or decreased respiratory rate and use of accessory musculature suggests hypoxia from any cause. Hypotension can signal vascular collapse from myocardial infarction, septic shock, or pulmonary embolus.
B. Additional physical examination. Stridor suggests upper airway obstruction. Examine the pharynx for evidence of obstruction. If epiglottitis or foreign body is suspected, be prepared to intubate the patient. Check the neck for evidence of jugular venous distention (JVD). Auscultate the chest for rales, suggesting pulmonary edema; wheezing and rhonchi consistent with reactive airway disease; or absence of breath sounds, suggesting pneumonia or pneumothorax. Auscultate the heart for murmurs, arrhythmias, and abnormal heart sounds. Feel the pulses in the extremities to assess for arterial embolus or venous thrombosis, especially if cyanosis is localized to one extremity. Examine the abdomen for evidence of intraabdominal catastrophe or aneurysm. Examine the nails for evidence of clubbing, suggesting chronic pulmonary disease.
Testing
A. Pulse oximetry estimates oxygen saturation, but does not measure it directly. Direct measurements using arterial blood gases (ABGs) are necessary to assess a cyanotic patient. Patients with abnormal hemoglobins will have a normal Pao2 but a decreased hemoglobin oxygen saturation. Cyanotic patients will have an o2 sat. less than 75% and a Pao2 less than 40 mm Hg if they have a normal hemoglobin concentration. A low Pao2 is caused by respiratory or cardiac problems in most circumstances.
B. A chest radiograph helps assess heart size and lung parenchyma. Infiltrates suggest pneumonia, ARDS, or pulmonary edema. Exclude pneumothorax. Look for evidence of interstitial lung disease. Pleural effusion can represent infection, malignancy, or pulmonary edema (Chapter 8.4).
C. An electrocardiogram may demonstrate acute myocardial infarction, arrhythmia, or pericardial process. P-pulmonale, right ventricular hypertrophy (RVH), and R axis suggest chronic pulmonary disease.
D. Other tests. Ventilation-perfusion scans may demonstrate pulmonary embolus. Pulmonary artery catheterization and pressure measurements help distinguish cardiac from pulmonary causes of cyanosis. Pulmonary function testing can help in the diagnosis of various pulmonary diseases.
Diagnostic assessment
A focused history, physical examination, and diagnostic testing will elucidate the cause of cyanosis in affected patients. Response to supplemental o2 can also help pinpoint the cause of cyanosis (2). Decreased oxygenation secondary to mild to moderate ·V/Q· mismatches caused by pneumonia, pulmonary embolus, and asthma may be reversible with supplemental oxygen. Severe ·V/Q· mismatch caused by intrapulmonary shunting from severe pulmonary edema or ARDS may be refractory to supplemental o2. Moderate ·V/Q· mismatch associated with ventilatory failure (COPD) may respond to supplemental o2, but be aware of increasing co2 levels. ABGs directly measure Pao2 and o2 saturation. Abnormal hemoglobins will also be measured and help guide therapy. Hypoxia with an elevated co2 suggests COPD or asthma, whereas hypoxia with a normal or decreased co2 suggests pneumonia, ARDS, pulmonary edema, pulmonary emboli, or interstitial lung disease (1). Once the cause of the cyanosis is determined, the objective is to treat the underlying process. Causes of pseudocyanosis include argyria or bismuth poisoning (slate blue-gray color), hemochromatosis (brownish color), or polycythemia (ruddy red color). For peripheral cyanosis caused by decreased cardiac output, correct the causes of hypovolemia (e.g., dehydration, shock, heart failure from whatever cause). Surgical consultation may be required for acute embolization of an extremity, and anticoagulation for venous thrombosis.
References
1. Khan MG. Cardiac and pulmonary management. Philadelphia: Lee & Febiger, 1993:818–825.
2. Woodley M, Whelan A. Manual of medical therapeutics. Boston: Little, Brown and Company, 1993:179–181.
3. Hurst JW. Medicine for the practicing physician. Boston: Butterworth–Heineman, 1983:973–975.
4. Collins RD. Dynamic differential diagnosis. Philadelphia: JB Lippincott, 1981:
386–388.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Cyanosis:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
Central cyanosis is best seen in the nailbeds or mucous membranes in good natural light. Peripheral cyanosis (due to increased capillary oxygen extraction) is seen in exposed areas such as the fingers, earlobes, and the tip of the nose. Massage or heat, which increase blood flow, will abolish peripheral but not central cyanosis.
The minimal amount of deoxyhemoglobin to cause central cyanosis is 2.38 g/dL. This is an absolute amount, so is dependent upon the hemoglobin concentration. For example, at a hemoglobin of 12 g/dL, cyanosis appears at SaO2 of 80%, while at a hemoglobin of 6 g/dL, cyanosis appears at SaO2 of 60%.
“Harlequin cyanosis” with one arm pink and the other blue can occur with aortic dissection, embolic arterial occlusion, or patent ductus arteriosis with pulmonary hypertension. Blue fingers and pink toes suggest complete transposition of the great vessels, preductal coarctation with a patent ductus arteriosis, or pulmonary hypertension with reversed flow through a patent ductus.
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Source: Field Guide to Bedside Diagnosis, 2007
Cyanosis:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin the physical assessment by taking vital signs. Evaluate respiratory rate and rhythm. Check for nasal flaring and use of accessory muscles. Inspect the skin and mucous membranes to determine the extent of cyanosis. Check the skin for coolness, pallor, redness, pain, and ulceration. Also note clubbing. Inspect the patient for asymmetrical chest expansion or barrel chest. Inspect the abdomen for ascites and test for shifting dullness or fluid wave. Palpate peripheral pulses, and test capillary refill time. Also, note edema.
Test the patient’s motor strength. Percuss the lungs for dullness or hyperresonance, and auscultate for decreased or adventitious breath sounds. Percuss and palpate for liver enlargement and tenderness. Auscultate heart rate and rhythm, especially noting gallops and murmurs. Also auscultate the abdominal aorta and femoral arteries to detect bruits.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Cyanosis:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
First taskis to decide whether cyanosis is peripheral or central. This isusually accomplished by history and physical exam.Presence of central cyanosis must beinvestigated immediately because of possibility of life-threateningheart or lung disease.Certain findings favor diagnosis oflung disease: respiratory distress or apnea in extreme prematureinfants in whom most common cause of lung disease is respiratorydistress syndrome; significant increase in PaO2 afteradministration of 100% oxygen (usually >150 mmHg); and elevated partial pressure of carbon dioxide (PCO2).Certain findings suggest heart disease:significant murmur, cardiomegaly, hepatomegaly, chest radiographwith decreased or increased pulmonary vascular markings, abnormalECG, marked generalized cyanosis with PaO2 thatdoes not improve significantly with 100% oxygen (usually <100mm Hg), and normal or decreased PaCO2.Absence of murmur does not rule outpossibility of heart disease.Examples of life-threatening cardiaclesions that may not be associated with murmurs include transpositionof great arteries with intact ventricular septum, pulmonary atresiawith intact ventricular septum, and total anomalous pulmonary venousreturn with obstruction.Infants with cyanotic heart diseasedo not usually have increased PaCO2,unless severe cardiac failure exists.Cardiac lesions causing decrease inblood flow or lack of adequate mixing (transposition of great arteriesand intact ventricular septum) present with severe cyanosis ± mildrespiratory distress. Cardiac lesions causing increase in pulmonaryblood flow present with respiratory distress, cardiac failure, andmild cyanosis.Chest radiographic findings of decreaseor increase in pulmonary vascular markings provide evidence of decreaseor increase in pulmonary blood flow, respectively, except in transpositionof great arteries with intact ventricular septum. In this lesion,pulmonary vascular markings may be mildly increased, but severecyanosis occurs because of parallel systemic and pulmonary circulationswith inadequate mixing of oxygenated blood.Degree of cyanosis, presence of respiratorydistress, and chest radiographic findings (increase or decreasein pulmonary vascular markings) can be used to categorize lesionsto help make a diagnosis.With suspected persistent pulmonaryartery hypertension in newborn, measurement of simultaneous PaO2 orarterial oxygen saturation (SaO2)at pre- and postductal sites (right radial and umbilical arteryor right finger and toe, respectively) may reveal right-to-leftductal shunt if preductal PaO2 or SaO2 ishigher. This finding also may be seen with severe coarctation ofaorta and interruption of aortic arch, but 2-D echocardiographycan usually confirm these diagnoses.When severe generalized cyanosis occursin infants who do not appear to have septicemia, certain tests shouldbe performed: CBC with differential, chest radiography, ECG, pulseoximetry in room air and in 100% oxygen, and 2-D echocardiography.In most cases, diagnosis can be made based on test results.If diagnosis is still uncertain andlife-threatening cyanotic congenital heart disease is possible,cardiac catheterization and angiography should be performed. >
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Cyanosis:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If cyanosis accompanies less-acute conditions, perform a thorough examination. Begin with a history, focusing on cardiac, pulmonary, and hematologic disorders. Ask about previous surgery. Then begin the physical examination by taking the patient's vital signs and pulse oximetry. Inspect the skin and mucous membranes to determine the extent of cyanosis. Ask the patient when he first noticed the cyanosis. Does it subside and recur? Is it aggravated by cold, smoking, or stress? Is it alleviated by massage or rewarming? Check the skin for coolness, pallor, redness, pain, and ulceration. Also note clubbing.
Next, evaluate the patient's level of consciousness. Ask about headaches, dizziness, or blurred vision. Then test his motor strength. Ask about pain in the arms and legs (especially with walking) and about abnormal sensations, such as numbness, tingling, and coldness.
Ask about chest pain and its severity. Can the patient identify aggravating and alleviating factors? Palpate peripheral pulses, and test the capillary refill time. Also, note edema. Auscultate heart rate and rhythm, especially noting gallops and murmurs. Also auscultate the abdominal aorta and femoral arteries to detect any bruits.
Does the patient have a cough? Is it productive? If so, have the patient describe the sputum. Evaluate his respiratory rate and rhythm. Check for nasal flaring and use of accessory muscles. Ask about sleep apnea. Does the patient sleep with his head propped up on pillows? Inspect the patient for asymmetrical chest expansion or barrel chest. Percuss the lungs for dullness or hyperresonance, and auscultate for decreased or adventitious breath sounds.
Inspect the abdomen for ascites, and test for shifting dullness or fluid wave. Percuss and palpate for liver enlargement and tenderness. Also, ask about nausea, anorexia, and weight loss.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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