PHYSICAL EXAMINATION Flashcards
Topographic markers on the chest include:
(a) The nipples.
(b) The angle of Louis (manubriosternal junction) that correlates to the second rib (reference point to begin counting ribs).
(c) The suprasternal notch.
(d) The Costal angle (usually no more than 90 degrees, with ribs inserted at 45-degree angles).
(e) The vertebra prominence (The spinous process of C7. It can be more readily seen and felt with the patient’s head bent forward. If two prominences are felt, the upper is that of the spinous process of C7, and the lower is that of T1).
(f) The clavicles (each intercostal space corresponds to that of the rib immediately above it).
Pregnancy
Estrogen increase causes
the ligaments of the rib cage to relax, and chest expansion increases.
1) An increase in the lateral diameter of about 2 cm and an increase in the circumference of 5-7 cm.
2) The subcostal angle progressively increases from about 68.5 degrees to approximately 103.5 degrees later in pregnancy.
3) The diaphragmatic movement increases and the major work of breathing is done by the diaphragm.
Pregnant women have deeper breathing and slightly increased rate of respirations.
Older adults
results from loss of muscle strength in thorax and diaphragm,
coupled with decreased lung resiliency.
The chest wall may stiffen, and expansion is decreased.
1:1 Ratio
Barrel chest
1) Loss of some interalveolar folds and tensile strength occurs, resulting in under ventilation of the ________ and a decreased tolerance for exertion.
2) These changes create a decrease in vital capacity and an increase in residual volume.
3) Dyspnea can occur when older adults exceed exertional demands.
This is due to what?
The alveoli: in older adults are less elastic and more fibrous.
a) The onset and nature of the cough (exercise, could it be asthma?
Persistent cough can sometimes be only symptom.)
b) Sputum characteristics
c) Pattern and severity of the cough
d) Associated symptoms (e.g., hoarseness)
e) Efforts to treat.
patient coughs or complains of coughing.
a) The onset of the problem
b) Pattern and factors facilitating or relieving it
c) Number of pillows the patient sleeps on at night (Orthopnea/platypnea)
d) Associated symptoms (e.g., such as diaphoresis)
e) Efforts to treat.
patient has or complains of shortness of breath.
(1 Constant ache lasting all day.
(2 Does not radiate.
(3 Made worse by pressing on the chest.
(4 Is a fleeting, needle-like jab that last only a few seconds.
(5 It is situated in the shoulders or between the shoulder blades in the back.
Complaints or signs of chest pain should be noted, along with their onset and duration, associated symptoms (e.g., fever), and any treatment efforts.
Other medications: Prescription or nonprescription, street drugs (e.g., cocaine)
Pertinent data include:
1) Past thoracic trauma or surgery
2) Use of oxygen
3) Chronic pulmonary diseases
4) Other systemic disorders (e.g., cancer), related respiratory tests, immunization against pneumonia, influenza, and the use of daily medications, both prescription and non-prescription.
Family History
(a) Tuberculosis
(b) Cystic fibrosis
(c) Empyema
(d) Allergies
(e) Smoking
(f) Malignancy
(g) Clotting disorders
(h) Risk of pulmonary embolism
(i) Bronchiectasis - Scarring of the tissue
(j) Bronchitis
Personal and Social History
(a) Work-related exposure to irritants, allergens, and hazards should be explored. Use of protective devices should be documented.
(b) Tobacco use: Type of tobacco (cigarettes, cigars, pipe, smokeless)
(c) Environmental factors in the home include type of heating, air conditioning, and humidification.
(d) Use of herbal or other remedies, consistent with complementary/alternative therapies.
(e) Other relevant data include:
1) Drug and alcohol consumption
2) Exercise tolerance: Diminished ability to perform up to expectations
3) Travel history (particular areas with high TB infections).
4) Potential exposure to respiratory infections, such as influenza, or tuberculosis.
5) Nutritional status: Weight loss or obesity
6) Hobbies
7) Use of Alcohol or recreational drugs
a) Owning pigeons
b) Parrots or other animals
c) Woodworking
d) Welding
Hobbies: within Social Hx
Pack years is what
Number of years of smoking X Number of packs smoked per day
Tobacco use:
1) Duration and amount
2) Age started
3) Efforts to quit smoking with factors influencing success or failure.
4) The extent of smoking by others at home or at work (passive smoking).
In young adults describe sever, acute chest pain, ask about recreational drug use, particularly cocaine.
Fact
Cocaine can cause severe acute chest pain associated with a pneumothorax and other chest related conditions.
The sequence of steps in examination of the chest and lungs is traditional:
Tangential lighting is utilized to highlight chest movement. Or good lighting.
inspection, palpation, percussion, and auscultation.
Barrel chest (Fig. 14-9), results from compromised respiration as in, for example what diseases?
and characteristics of Barrel chest?
chronic asthma, emphysema, or cystic fibrosis.
2) The ribs are more horizontal, the spine is at least somewhat kyphotic, and the sternal angle is more prominent.
3) The AP diameter approaches or equals the lateral diameter (a ratio of 1.0 or even greater), there is most often a chronic condition present.
Clubbing of fingernails is indicative of
prolonged respiratory/cardiac distress.
Smell for odors of the breath
Sweet smell
diabetic ketoacidosis
Smell for odors of the breath
Ammonia
uremia
Smell for odors of the breath
Musty fish
hepatic failure
Smell for odors of the breath
Foul/feculent
intestinal obstruction/diverticulum
Smell for odors of the breath
Foul/putrid
respiratory infection (empyema, lung abscess, bronchiectasis)
Smell for odors of the breath
Halitosis
gingivitis, Vincent’s angina
Smell for odors of the breath
Cinnamon
tuberculosis
Normal rate and ratio of RR and HR
(a) Rate should be 12-20 respirations per minute
(b) Ratio of respirations to heartbeats is approximately 1:4
LOOK AT IT
Absence of spontaneous respirations.
Apnea-
the feeling or sensation that one cannot breath well enough. Distinct sensations include effort/work, chest tightness, and air hunger (the feeling of not enough oxygen)
Dyspnea-
Grave condition in which breathing stops and will not
spontaneously start again unless resuscitative measures are immediately instituted.
Secondary Apnea-
Shortness of breath that begins or increases when the patient lies down; ask whether the patient needs to sleep on more than one pillow and whether that helps.
Orthopnea-
A sudden onset of shortness of breathe after a
period of sleep; sitting upright is helpful.
Paroxysmal nocturnal dyspnea-
Dyspnea increase in the upright posture.
Platypnea-
A persistent respiratory rate faster than 20 and approaching 25 breaths per minute. (May be observed in those with metabolic acidosis).
Tachypnea-
A rate slower than 12 respirations per minute may indicate
neurologic or electrolyte disturbance, infection or a sensible response to protect against the pain of pleurisy (it may also indicate a splendid level of cardiorespiratory fitness).
Bradypnea-
A regular periodic pattern of breathing, with intervals of apnea followed by a crescendo/decrescendo (children and older adults may breath in this pattern during sleep, but it occurs in those with brain damage at the cerebral level or with drug- associated respiratory compromise).
Cheyne Stokes Respirations-
Somewhat irregular respirations varying in depth and
interrupted by intervals of apnea but lacking the repetitive pattern of periodic respirations of Cheyne Stokes.
Biot Respirations-
Respirations greater than 20, and deep (hyperventilation)
Hyperpnea-
Rapid, deep and labored respiratory pattern associated
with metabolic acidosis.
Kussmaul breathing-
Regular comfortable breathing at a rate of 12-20 breaths per minute.
Eupnea-
With obstruction high in the respiratory tree (e.g. tracheal or laryngeal involvement, or below the glottis) characterized by stridor, and the chest wall seems to cave in at the sternum, between the ribs (intercostals), at the suprasternal notch, above the clavicles and at the lowest costal margins. It’s also indicative of a more severe obstruction in the asthmatic patient.
Fact
Retraction of the lower chest occurs with
asthma and bronchiolitis.
Take note of Pectus Excavatum (Fig 14-12A) (Funnel Chest) and Pectus Carinatum (Fig 14.12B) (Pigeon Chest)
Look at it
Barrel Chest that results from compromised respiration as in, for example, of what disease AGAIN?
Barrel Chest presents with an increase in the anteroposterior diameter (a ratio of 1.0 or even more) as well as a widened costal angle (greater than 90 degrees)
chronic asthma, COPD, emphysema, or cystic fibrosis.
Look for Clues at the Periphery: Lips and nail you are looking for?
Observe the lips and nails for cyanosis, the lips for pursing, the fingers for clubbing, and the alae nasi for flaring.
Any of these peripheral findings suggests pulmonary or cardiac disease or dysfunction.
Palpation: what are you palpating and looking for? 5 things
- anterior and posterior chest bones and muscles for pulsations, pain, bulges, movement, depression, crepitation, and positions.
- crepitus that is indicative of a rupture somewhere in the respiratory system.]
- thoracic expansion
- tactile fremitus
- suprasternal notch and inner borders of sternocleidomastoids to assess the trachea.
Increased fremitus often is coarser or rougher in feel, occurs
from the presence of fluids or a solid mass in the lungs and may be caused by consolidation.
Percussion
Resonance is the expected sound, and can be heard over all areas of the lungs.
Hyperresonance associated with
hyperinflation may indicate emphysema,
pneumothorax, or asthma.
Percussion
Dullness or flatness suggests
atelectasis, pleural
effusion, pneumothorax or asthma.
Percussion
Tympany
is the sound usually associated with
percussion over the abdomen.
Measure diaphragmatic excursion (fig. 14.20). Note that the diaphragm usually higher on the right side than on the left, due to the liver.
(a) Percussion should be done along the scapular line.
(b) Excursion is usually 3 to 5 or 6 cm (excursion will be decreased in patients with COPD)
Look at it
provides the greatest amount of information
Auscultation-
Auscultation
Breath sounds are usually listened to with the
diaphragm of the stethoscope.
Auscultation
The right middle lobe is best auscultated at the
anterior axillary line at the 5th
intercostal space.
Auscultation
The right middle lobe is best auscultated at the
anterior axillary line at the 5th
intercostal space.
Auscultation
Vesicular sounds are heard over most of the lungs fields, they are
soft, low
pitched.
Auscultation
Broncho vesicular sounds are heard over the main stem bronchi and over the
upper right posterior lung field, they are medium pitched.
Auscultation
Bronchial/Tracheal sounds are heard only over the
trachea and are high pitched.
Auscultation
Vocal Resonance:
The spoken voice vibrates and transmits sounds through the lung fields
Auscultation
is defined as greater clarity and increased loudness of spoken
sounds. Usually spoken words will be unintelligible and muffled.
Bronchophony
Auscultation
whispered sounds will normally not be heard or be
completely unintelligible.
Whispered pectoriloquy
Auscultation
is noted when consolidation (general) is present and the patient speaks the letter “e”, what is actually auscultated are broad stuffy “a’s”. The expected findings are muffled “e’s”.
Egophony
Adventitious Breath Sounds
1) Abnormal sound heard more often during inspiration and characterized by discrete discontinuous sounds, each lasting just a few milliseconds.
2) Traditionally the term “rales” had been used, however, the American Thoracic Society officially recognizes crackles.
3) They may be fine, medium or coarse, and crackles will NOT be cleared by coughing
Crackles
Adventitious Breath Sounds
1) Are deeper, more rumbling, more pronounced during EXPIRATION, more likely to be prolonged and continuous, and less discrete than crackles.
2) It may be difficult to distinguish crackles and rhonchi. In general, tend to disappear after coughing, whereas crackles do not.
Rhonchi (Sonorous Wheeze)
Adventitious Breath Sounds
1) It is a continuous, high pitched, musical sound (almost a whistle) heard during inspiration or expiration.
Wheezes (Sibilant Wheeze)
Adventitious Breath Sounds
1) A high-pitched, wheezing sound caused by disrupted airflow, usually caused by blockage in the larynx or trachea.
2) Can be inspiratory or expiratory.
3) Heard best over the anterior neck.
Stridor:
Adventitious Breath Sounds
1) Occurs outside the respiratory tree, it has a dry, crackly low pitched sound and is heard in both expiration and inspiration.
2) disappears when the breath is held
Friction Rub
Examination Findings
1) Anteroposterior diameter is half the size of transverse diameter.
2) Respiratory rate is 12 to 20 per minute.
3) Ratio of respirations to heartbeat is 1:4.
4) Chest expansion is equal bilaterally.
5) Bronchial, bronchovesicular, and vesicular breath sounds heard on auscultation.
(a) Normal findings
Typical variations
Decreased tactile or vocal fremitus is associated with
emphysema
Typical variations
lateral curvature/deviation of the spine.
Scoliosis
Typical variations
excessive inward curvature of the lumbar spine.
Lordosis
Typical variations
Dullness indicates lung ____________
Work-related exposure to irritants and allergens and use of protective devices should be explored.
consolidation.
Typical variations
Hyper-resonance indicates
hyperinflation of lungs
Findings associated with disorders
Shallow respirations are associated with
injured rib, pleurisy, liver enlargement, or abdominal ascites.
Slow respirations may mean neurologic
or electrolyte problems, infection, or pleurisy.
Findings associated with disorders
Barrel chest with kyphosis, prominent sternal angle, and obstructive pulmonary disease is associated with
Chronic disease
Findings associated with disorders
Asymmetric, unequal expansion of the lungs may be caused by
extra pleural air, fluid, or mass.
Chest asymmetry suggests pneumothorax.
Findings associated with disorders
Expiratory bulging may indicate
enlarged heart, tumor, or aneurysm.
1) Estrogen increase causes ligament of rib cage to relax; chest expansion increases.
2) Lung length decreases and diaphragm rises.
(b) Typical variations
1) Costal angle up to 103 degrees in pregnancy.
2) Rib cage flares.
3) Deep thoracic breathing occurs. Dyspnea is common and is usually the result of normal physiologic changes.
(c) Findings associated with disorders.
1) None listed.
Normal findings in Pregnant women
1) With aging, there is loss of muscle strength of thorax and diaphragm, resulting in decreased lung resiliency.
2) Alveoli are less elastic and more fibrous.
(b) Typical variations
1) Older adults have less chest expansion; larger anteroposterior diameter; and marked, bony prominences.
2) Aging is associated with kyphosis, use of accessory muscles, and hyper resonance.
(c) Findings associated with disorders
1) Cheyne-Stokes respiration implies serious condition.
2) Chest pain should be noted along with onset, duration, and associated symptoms of diaphoresis or shortness of breath.
Older adults: Normal findings
Common Respiratory Disease
A persistent cough may be the only manifestation. (Peak expiratory flow rates (PEFR’s) should be obtained before and after nebulizer treatments to verify improved lung function).
Asthma (Reactive Airway Disease)
Common Respiratory Disease
(a) Inflammatory process involving the pleural and parietal pleura.
(b) The resultant rub can be heard and felt during exam.
Pleurisy
Common Respiratory Disease
(a) Diminished breath sounds and dullness to percussion occur over the area of consolidation.
(b) Involvement of the right lower lobe can stimulate the tenth and eleventh thoracic nerves to cause right lower quadrant pain and simulate an abdominal process.
Pneumonia
Common Respiratory Disease
(a) The presence of air or gas in the pleural space.
(b) A positive coin click can help diagnose, place a coin over the suspicious area in the chest, and while listening to the opposite side, have someone strike the coin with the edge of another.
(c) A clear click will be heard only in the event of this pronounced disease.
Pneumothorax
Common Respiratory Disease
(a) A collection of purulent exudates in the pleural space.
Empyema
Common Respiratory Disease
(a) Both characterized by dullness heard on percussion.
Pleural effusion and lobar pneumonia
Common Respiratory Disease
(a) An autosomal recessive disorder of the exocrine glands involving the lungs, pancreas and sweat glands.
(b) Characterized by abnormally thick mucus and subsequent pulmonary infections.
Cystic Fibrosis
Common Respiratory Disease
A condition where PH level of the entire body has decreased (increased hydrogen ion concentration) which will trigger increased respiratory rate.
Metabolic acidosis
At ambient temperature and pressure (ATP), oxygen atoms bind together, sharing
electrons to form molecules of oxygen that exist as a colourless, odourless
transparent and tasteless gas with the chemical symbol O2.
Fact
At ambient temperature and pressure (ATP), oxygen atoms bind together, sharing
electrons to form molecules of oxygen that exist as a colourless, odourless
transparent and tasteless gas with the chemical symbol O2.
Fact
At ambient temperature and pressure (ATP), oxygen atoms bind together, sharing
electrons to form molecules of oxygen that exist as a colourless, odourless
transparent and tasteless gas with the chemical symbol O2.
Fact
(a) Makes up 20.9% of air by volume and 23% air by weight.
(b) Constitutes 50% of Earth’s crust by weight (in air water and combined with other elements).
(c) Can combine with all other elements except other inert gases to form oxides.
Oxygen Molecules
(a) Is a non-flammable gas.
(b) Accelerates combustion.
(c) At -182.9C (-300 f) oxygen is a pale blue liquid.
(d) Its critical temperature is -118.4 C (above this critical temperature oxygen can only exist as a gas regardless of the pressure.)
(e) An oxygen enriched environment is considered to have 23% oxygen in the air and is a fire hazard.
Oxygen is therefore characterized as an oxidizer.
The Food and Drug Act:
A “drug” includes any substance or mixture of substance manufactured, sold or represented for use in:
(a) The diagnosis, treatment, mitigation or prevention of a disease, disorder or abnormal physical state, or its symptoms in human beings or animals.
(b) Restoring, correcting or modifying organic functions in human beings or animals
(c) Disinfection in premises in which food is manufactured, prepared or kept.
(1) Oxygen toxicity
(2) Oxidative stress
(3) Depression of ventilation in a select population with chronic hypercarbia
(4) Retinopathy of prematurity
(5) Absorption atelectasis
Potential Adverse Effects of oxygen
“To treat or prevent hypoxemia thereby preventing tissue hypoxia which may result in tissue injury or even cell death.”
The main goal of oxygen therapy is:
