Examination and Assessment handbook (1) Flashcards

Question

Trachea observation

Answer 1

Trachea Centrally positioned or deviated to one side

Answer 2

Thorax Shape e.g. barrel chest, funnel chest, scoliosis, kyphosis Surgical Scars – previous thoracic or cardiac surgery

Answer 3

Abdomen Distension / obesity

Answer 4

Hands Finger clubbing (nail bed bulging associated with chronic cardiorespiratory disease) Tremor or flapping (associated with increased C02) Nicotine stains Blue fingers (peripheral cyanosis = inadequate peripheral circulation)

Answer 5

Ankles Oedema (cardiac failure, immobility, poor venous return)

Answer 6

Cough is a prominent symptom forpatients with cardiorespiratory disease Assessment of it can provide important information

Answer 7

Most patients will cough readily some will present with a weak, ineffective or absent cough. The ability to cough is an essential part of airway defence and should always be assessed thoroughly

Answer 8

Dry :Clear cough sound with no audible respiratory secretions. NB// Does not necessarily mean there is no sputum Wet :Audible secretions in the lower respiratory tract Rattling :Audible secretions in the upper respiratory tract Productive : Patient is expectorating (spitting out) sputum after coughing Need to describe the sputum (see below)

Answer 9

1)Clear - Saliva-like Not indicative of infection 2)Mucoid - White/milky, opaque Viral infection or non-infective bronchitis 3) Purulent - Yellow/Green, pus-likeBacterial infection (colour is from dead neutrophils) 4) Frothy -Pink or white froth Pulmonary oedema 5)Frank haemoptysis- Pure blood Pulmonary haemorrhage, TB, tumour, cavity, lung infarction, pulmonary embolus. 6)Streaked haemoptysis- Blood mixed with white/purulent sputum Inflammation of bronchial tree, tumour, cavity

Answer 10

Observe the patient’s breathing pattern for one minute at rest and consider the following: See notes

Answer 11

A stethoscope is used to listen to the chest and identify normal and abnormal sounds Used as an investigation and outcome measure

Answer 12

• Eliminate noise: close door, turn off radios/ TV. • Patient :sitting up in bed or a chair. If possible patient should not be leaning against anything – they may need help to sit forwards. * Ask the patient to take their top off (if possible) or ask permission to move the patient’s clothing out of the way - your stethoscope should be touching the patient’s bare skin. * Always ensure patient comfort. Be considerate and warm the diaphragm of your stethoscope with your hand before auscultation.

Answer 13

• posterior chest: ask the patient to keep both arms crossed in front of his/her chest, if possible. • Ask the patient to breathe deeply through the mouth. Be careful of hyperventilation. Listen to at least one full inspiration & expiration in each location. • It is important that you always compare what you hear with the opposite side. e.g. If you are listening to the left apex, you should follow through by comparing what you heard with what you hear at the right apex. • Generally, listen to at least 6 locations on both the anterior and posterior chest. • Begin by auscultating the apices of the lungs, moving from side to side and comparing as you approach the bases.

Answer 14

Palpation is used as part of the assessment to further investigate the observed and auscultated findings. An explanation for palpation should be provided and consent obtained from the patient.

Answer 15

Assess whether the trachea is central or deviated

Answer 16

Thorax Palpate upper chest over main bronchi Palpate lower chest, laterally Assess for symmetry of movement Assess for quality of expansion during deep breath Assess for bronchial fremitus (vibration indicating secretions)

Answer 17

Clavicles Palpate for surgical emphysema (feels like bubble wrap)

Answer 18

Abdomen Assess for distension Assess for expiratory accessory muscle use

Answer 19

Hands Assess for temperature Assess for swelling

Answer 20

* You will need to be able to see a clock or watch that has a second hand. * Make sure that the patient is comfortable & as relaxed as possible - one who is distressed may have a faster pulse. • Place your first and second finger along the artery which can be palpated just medial to the radial styloid process. Apply light pressure until you feel the pulse. • Count the pulse for 30 seconds, multiply this measurement by 2 and record the heart rate in beats per minute

Answer 21

If a patient is aware of their respiratory rate being counted

Answer 22

perform the pulse rate assessment (as above) then: * Without releasing the patients wrist look for movement of the ribs or abdomen as the patient breathes * Count the number of breaths the patient takes in 30 seconds * Multiply this measurement by 2 and record the respiratory rate in breaths per minute * NB/ in some clinical areas it is necessary to count the respiratory rate for a full minute e.g. post-surgery

Answer 23

The following measures may be used to assess the patient initially and/or to use as ongoing outcome measures to assess the effectiveness of the intervention.

Answer 24

Peak flow Spirometry Pulse Oximetry Exercise Testing Cardiopulmonary Exercise Testing (CPET) Incremental shuttle walking test (ISWT) 6 minute walking test (6MWT Chester step test

Answer 25

Used to assess the patient initially and/or to use as ongoing outcome measures to assess the effectiveness of the intervention. Simple and cheap test that measures maximum expiratory rate (fastest speed patient can breathe out) using a peak flow meter. In healthy adults normal PEFR is 400-650L/min which varies according to age, height and sex. Significant variability in PEFR = PEFR readings should be viewed with the overall trend.

Answer 26

* Explain to the patient the purpose of PEFR and obtain consent. * Attach a clean or disposable mouthpiece * Set the arrow to the zero mark * Position the patient upright - sitting upright or preferably standing up • Ask the patient to take a maximal inspiration then to close her or his lips around the mouthpiece and to exhale as forcibly as possible • Note the measurement • Repeat the process a further two times ensuring that the arrow is reset to the zero mark for each measurement. • Dispose of the mouthpiece (if appropriate), and ensure that the equipment is clean • Make a note of the highest value reached, documenting specific time/previous medication • Compare the measurement against a recognised chart of normal values, and more importantly against the individual's normal value.

Answer 27

Spirometry can be used to measure all lung volumes except residual volume and functional residual capacity. In the clinical setting a useful measure is that of the FEV1/FVC ratio as it is a measure of airway limitation. • FEV1 & FVC are related to height, age and sex of the patient • SFEV1 – volume of air expelled in the first second of a forced expiration, starting from full inspiration • FVC – total volume of air expelled during a forced exhalation starting from full inspiration

Answer 28

• Explain to the patient the purpose of spirometry and obtain consent. • Attach a clean or disposable mouthpiece to the spirometer & enter the patient’s age, sex & height into the spirometer when prompted. • Position the patient upright - sitting upright or preferably standing up • Ask the patient to take a maximal inspiration then to close her or his lips around the mouthpiece and to exhale as hard and as fast as possible * Instruct the patient to keep breathing out until the lungs are 'empty'. * Note the measurement • Some patients may need to practice just emptying their lungs without the Spirometer before getting them to attempt the test • Three satisfactory blows should be performed and best values taken for interpretation. • Dispose of the mouthpiece, and ensure that the equipment is clean. • Make a note of the highest value reached, documenting specific time/previous medication. • Compare the measurement against a recognised chart of normal values – the spirometer may do this automatically.

Answer 29

Pulse oximetry is a procedure used to measure the oxygen level (or oxygen saturation) in the blood. It is considered to be a non-invasive, painless, general indicator of oxygen delivery to the peripheral tissues. Pulse oximetry measures the percentage of haemoglobin that is carrying oxygen by shining an infra-red light into the patient’s finger (or ear lobe). Oxy-haemoglobin absorbs more infra-red light than deoxy-haemoglobin therefore the oximeter can detect the proportion of oxy-haemoglobin to deoxy-haemoglobin. Normal values are 95-98%. Inaccurate readings may be obtained with severe hypotension, low cardiac output, vasoconstriction and hypothermia, all of which reduce the volume of blood to the tissues

Answer 30

Allows the assessor to: * Determine the level of functional impairment and activity limitation * Determine factors which may limit exercise capacity * Provide guidance for exercise prescription • Identify oxygen desaturation during exercise and aid prescription of supplemental oxygen • Evaluate the effectiveness of rehabilitation in altering exercise capacity A number of methods may be used to assess exercise capacity.

Answer 31

This is considered the ‘gold standard’ of exercise testing its a maximal exercise test and gives detailed information on the cardiorespiratory system during exercise and indicates the limitations to exercise. The maximal oxygen uptake (V02max) can be determined as well as the individual’s anaerobic threshold.

Answer 32

expensive laboratory equipment specialised staff Physiologists unsafe for some patients =sub-maximal ‘field tests’ have been developed which show patient’s functional exercise capacity.

Answer 33

Incremental shuttle walking test (ISWT) 6 minute walking test (6MWT Chester step test

Answer 34

This walking test was designed to simulate a cardiopulmonary exercise test and is a walking version of the ‘bleep test’. The patient is required to walk between two cones in time to a set of auditory beeps played on a CD.

Answer 35

The patient walks 30m shuttles for 6 minutes and the distance walked is recorded. For full instructions follow this link

Answer 36

Patient steps on and off a step of a pre-determined height at a set rate with external audio cues (beats). After each level is completed, the rate of stepping increases. It is essentially a step-up version of the bleep test. The Chester Step Test is typically used to assess patients pre- and post-cardiac rehabilitation programmes, whereas the walking tests (ISWT & 6MWT) are typically used to assess patients pre- and post-pulmonary rehabilitation.

Answer 37

After clinical examination, the most commonly used special investigation of the thorax is the chest x-ray. When viewing a CXR, you should employ a systematic approach Look at link

Answer 38

P.A. (postero- anterior) is the usual view in which the subject sits or stands with the anterior surface of the chest against the film and the x-ray tube behind. The patient is asked to take a deep breath in and hold it at which point the x-ray is taken. A.P. (antero-posterior) is when the film is placed behind the patient and the x-ray tube is in front, that is the beam passes from anterior to posterior. A.P. films are used for ill patients in the I.C.U. and wards. *Note that if an object is near the film there is little magnification but if the object is further away there is more magnification that is in an A.P. film the heart is magnified. Lateral view is used to assess distribution and localisation of abnormal shadows seen on P.A or A.P. Oblique view is used to demonstrate ribs, to assess the heart and aorta and in bronchography. Decubitus view is taken with the x-ray beam horizontal to the floor and the patient lying on their side in a P.A. position. It is used to show the flow of fluid when an effusion is suspected when there is difficulty interpreting the P.A. film.

Answer 39

1. Name, date and time. 2. Projection: P.A./A.P./lateral etc 3. Centering – is the patient rotated? That is are the clavicle ends and spine symmetrically disposed? 4. Correct exposure? Chest x-rays demonstrate: • Hard tissues • Soft tissues • Lung fields and associated structures

Answer 40

seen crossing the apices of the lungs

Answer 41

Ribs - Seen as they curve around the thorax, running parallel. Posterior parts are seen most clearly, run horizontally or slightly downwards and the anterior ends curve down and in. The costal cartilages are invisible except when they become calcified. The 10th rib should be seen if the x-ray is taken in full inspiration. Check general shape, density, direction and spacing. Abnormalities 1. Congenital anomaly in number of ribs 2. Bifid ribs 3. Fractures 4. Metastases

Answer 42

largely hidden by the vertebrae

Answer 43

only just visible on a properly exposed P.A. chest film Scoliosis and Kyphosis may be seen.

Answer 44

medial border and inferior angle should be identified

Answer 45

Vary in size and shape and can be asymmetrical Gynomastia may be seen in males Absence of one or more breasts affects the translucency of the lung bases. Nipples may cast a shadow.

Answer 46

The edge of sternocleidomastoid often seen as a vertical line running outwards from the medial end of the clavicle Pectoralis Major – increased shadowing over the middle and upper parts of the chest. When absent this can give rise to hypertranslucency and misleading impression of emphysema.

Answer 47

2 domes, convex upwards. Laterally the diaphragm meets the chest wall at the acute costo-phrenic angle. Centrally a tendinous part of the diaphragm is fused to the pericardium and at each side there is a cardiophrenic angle. The right dome is usually 1 – 3cms higher than the left due to the liver pushing up against it, seen at the 10th rib posteriorly. Abnormalities Unilateral elevation of a dome – due to gas distension, inflammatory changes in the lungs and pleura, sub-phrenic abscess, pulmonary collapse with the diaphragm rising to fill the space left by the diminished lung volume, pulmonary embolus (PE), hepatomegaly, splenomegaly, phrenic palsy Bilateral elevation – due to pressure from below – obesity, pregnancy, ascites, tumour. In the sub-diaphragmatic area gas may be seen in the gastric fundus and splenic flexure. The under surface of the (R) dome normally inseparable from the liver shadow.

Answer 48

mediastinal shadow due to the heart and great vessels. It should be examined with respect to size, shape and position. Heart is in the centre of the thorax, outline projection is 1/3rd to (R) and 2/3 to (L). The normal cardiothoracic ratio is usually 1:2 for a normal adult male. The translucency of the trachea overlies two cervical and upper 5 thoracic vertebrae. It usually lies centrally or just to the (R) of midline and its walls are parallel to each other. The bifurcation into the major bronchi can usually just be identified. The (R) main bronchus enters the lung at the level of T5 and the (L) at T6.

Answer 49

produced by the main and lobar branches of the pulmonary arteries and veins and hilar lymph glands. The (L) hilar shadow appears 1-2cms higher than the (R).

Answer 50

Radiotranslucency – in normal lungs, the translucency at a given level should be equal on both sides.

Answer 51

constitute the lung markings, almost entirely arterial. These should be traced from the hilum on each side. The pattern should be compared on the two sides. Normally vessels appear larger and more numerous in lower zones (due to erect posture) and increased blood in dependent regions.

Answer 52

Can only be visualised if they lie tangentially to the path of the x-rays. In the P.A. film the, horizontal fissure can be seen from the right hilum to the mid-axillary line in the 5th intercostal space in over 75% of cases. A lateral film is needed to see the oblique fissure.

Answer 53

For radiographic examination 3 zones are identified. Upper zone – portion of lungs lying above the line drawn horizontally at level of anterior ends of the 2nd rib Mid zone – between upper zone and above horizontal line drawn at level of anterior ends of 4th ribs Lower zone – portion of chest below anterior ends of 4th ribs Review Areas: 4 areas require particular attention * Apices * Hilar regions * Heart shadow * Costophrenic angle

Answer 54

Indicates the state of the lung where the alveolar air has been replaced by * Cellular exudates e.g.pneumonia * Transudate, e.g. pulmonary oedema * Blood – trauma, inhalation, infarction * Neoplastic cells, the alveoli remaining intact Appearance of airlessness without shrinkage. Radiographic appearance the same whatever the cause and often whatever the stage of consolidation. Consolidation may be: Complete - All air in affected area has been replaced. Degree of radiopacity depends on the thickness of consolidation in the line of the x-ray beam. Homogenous shadowing, loss of vascular markings. Although alveoli contain fluid bronchi will probably still contain air which contrasts with shadow = air bronchogram Incomplete - Only some of the alveoli are affected and there is only a slight increase in the overall radiopacity – may show as fine mottling or as a faint ground glass shadowing. Consolidation may also be lobar, sub-lobar, segmental or sub-segmental.

Answer 55

Appearance of airlessness with shrinkage >ATELECTASIS absorption collapse as a sequel to bronchial obstruction, due to; Extrinsic pressure - tumour, glandular mass, aneurysm Intrinsic disease – bronchial Ca, granulation tissue, exudates Viscid sputum – asthma Inhaled material – foreign body, blood Smaller area of lung affected than with collapse. >COLLAPSE: compression collapse, usually lobar or segmental caused by: * Large pleural effusion * Tumour * Tension pneumothorax * Ascites, hepatomegaly, splenomegaly all cause local collapse >Appearance the same whatever the cause and is modified by several factors: * Degree of shrinkage * ? accompanying consolidation * State of pleura * Pre-existing condition of lung Full collapsed lung: the hemithorax of the affected side will be radio opaque. Partial collapsed lung: (lobe, segment, sub-segmental) and there is no accompanying consolidation, there will be no increase in radiopacity. Only evidence will be a shift in normal landmarks – position of fissures, vascular pattern, hilar shadow

Answer 56

Accumulation of excessive fluid in the interstitial spaces of the lung with subsequent movement of fluid into the alveolar spaces. Due to imbalance between rate of production and removal. ``` Many causes – some examples • Heart failure • Fluid overload – excess i.v. fluid, renal failure • Cerebral disease – CVA, trauma • Liver disease ```

Answer 57

Air within the pleural cavity. * Spontaneous – commonly caused by rupture of emphysematous subpleural bleb * External entry of air, for example due to a penetrating wound • From the mediastinum, for example due to a ruptured trachea,bronchus, oesophagus. Pneumo-mediastinum may result from violent coughing Large pneumothorax may cause mediastinal shift to the normal side, the displacement increasing on expiration. A small pneumothorax is best demonstrated on P.A. radiograph exposed on expiration (usually performed routinely on a patient with a suspected pneumothorax.

Answer 58

Reduction in size and number of vascular markings, best seen in middle and outer thirds of the lungs. Air trapping shows an increase in the volume of lung – ‘over inflation’ and flattening of the contours of the diaphragm. Heart shadow often long and narrow and the cardiothoracic ratio at 1:3 or 1:4. Lung fields usually appear more translucent.

Answer 59

These are thin walled spherical or oval translucencies which vary in diameter from a few mm to several cms. Often seen at the periphery of the lung at the base or apex. Their walls are smooth and regular. They are often difficult to differentiate from a pneumothorax.

Answer 60

Often no specific radiological signs, but the x-ray should be examined to assess degree of emphysema, determine whether cardiovascular changes or cor pulmonale are developing and to determine the presence of other disease, for example, TB. There may be: * Small ill-defined opacities seen anywhere in the lungs which may indicate small areas of consolidation or scarring from previous inflammation * Linear shadows – may represent old fibrotic changes * Altered vascular pattern

Answer 61

Only one third of chronic asthma patients exhibit radiographic abnormalities. There may be: * Airways obstruction may lead to over inflation of lungs, lowering of the domes of the diaphragm * Transient areas of consolidation * Alteration in vascular markings.

Answer 62

Uses ultrasound waves to produce an image of the thoracic structures. Can differentiate between consolidation and effusion and can also assess diaphragm function. It is portable and does not expose the patient to radiation therefore is a useful alternative to CT imaging. Some specialised physiotherapists are additionally trained to carry out TUS.

Answer 63

Physiotherapist working with both in-patients and out-patients with cardiorespiratory problems will have access to a variety of blood test results. The most relevant to physiotherapists are usually the arterial blood gas (ABG) and the full blood count (FBC)

Answer 64

Blood gas analysis gives a reading of the partial pressures exerted by oxygen and carbon dioxide dissolved in the plasma of arterial blood. It also measures the pH and the level of bicarbonate in the blood. The base excess (BE) is a calculated figure (i.e. not directly measured) which provides an estimate of the surplus amount of alkali within the blood.

Answer 65

Normal values for ABGs: 1. pH 7.35-7.45 2. PaCO2 4.7-6.0 3. PaO2 10.7-13.3 4. HCO3- 22-26 5. BE -2 to +2

Answer 66

This will provide information about the number and type of cells found within the blood. Raised white cell count (WCC) may indicate infection, reduced haemoglobin (Hb) may indicate blood loss and low platelets may indicate an increased likelihood of bleeding.

Answer 67

Normal Values: Haemoglobin (Hb) Males 130–180 g/ L Females 115–165 g/ L White cell count (WCC) Total 3.6–11.0 × 109/ L Neutrophils 1.8–7.5 × 109/ L Lymphocytes 1.0–4.0 × 109/ L Monocytes 0.2–0.8 × 109/ L Eosinophils 0.1–0.4 × 109/ L Basophils 0.02–0.10 × 109/ L Platelets 140–400 × 109/ L

Answer 68

A = Airway Note type of airway – ETT (artificial airway from mouth to trachea), tracheostomy, patient’s own B = Breathing Note method of ventilation – self, ventilator, mode, fraction of inspired oxygen (Fi02), ventilator settings Respiratory observations - RR, ABGs, Sa02 Look, listen and feel (observation, auscultation, palpation) assessment of respiratory function CXR, CT scan C = Circulation Cardiovascular system observations - HR, BP, ECG trace, note any inotropes. D = Disability Sedation level, alertness (AVPU), note any sedatives, recent paralysing agents Muscle power, functional ability, PROM E = Exposure Note all attachments and awareness of purpose/importance Observe limb oedema, temperature, skin colour e.g. Mottled Wounds, incisions, injuries (trauma patient).

Answer 69

The patient lies on a table then, using an x-ray tube and detectors, a computer reconstructs signals received from the detectors. The images acquired are transverse (axial) cross-sections of the patient. To orientate the patient, it is convention to view all CT images as if it from the patient’s feet. It can be used to localise tumours and assist with the diagnosis of bronchial, alveolar and interstitial lung diseases. It is a costly procedure and exposes the patient to a dose of radiation, however it is the gold standard for lung imaging

Answer 70

This type of assessment is used when assessing an acutely unwell patient. It is a standardised assessment used by all medical professionals in emergency situations. You may be required to assess routine patients in this format in acute care settings such as intensive care or high dependency.

Answer 71

Fluid within the pleural cavity. Homogenous shadow devoid of pulmonary markings. Pleural fluid occupies space in the thorax at the expense of underlying lung which retracts towards the hilum –appearance depends on the elasticity of the lung. Presence or absence of pleural adhesions may cause loculations of fluid.

Brainscape's Knowledge GenomeTM

Examination and Assessment handbook (1) Flashcards

Brainscape's Knowledge Genome^TM