Physical Examination Flashcards
Componenets of INSPECTION
(5)
- Vital Signs
- Mechanism of Ventilation
- Throacic Shape
- Head, Neck, & Extremities
- Speech, cough, & sputum
Vital Sign: Components of Assessment
- Heart Rate
- Respiratory Rate
- Blood Pressure
- SpO2
Heart Rate
Rate & Rhythm
Rate:
- Bradycardia: <60 bpm
- Normal: 60-100
- Tachycardia: >60 bpm
Rhythm:
- Normal: regular consistent pattern “lub dub”
- Irregular: irregular but consistent pattern (bigeminy, trigemini)
- Irregular irregular: irregular but inconsistent pattern (atrial fibrillation)
Respiratory Rate (RR)
Rate - Adults & Babies
Inspect covertly (not obvious) - do not tell patient you are assessing RR
Bradypnea: Less than 12 breaths/min
Normal: 12-20 breaths/min
Tachypnea: >20 breaths/min
Age & Breath Rates:
Newborn = 35-40 (faster to meet metabolic demand)
Infant (6 months) = 30-50
Toddler (2 years) = 25-32
Child = 20-30
Adolescent = 16-20
Adult = 20
Blood Pressure
Procedure Details & Values & Consideration
Procedures
- Palpate brachial artery
- Cuff is 1 inch above the pulse
- Inflate the cuff until brachial pulse dissapears then add 20 mmHg - process is called “obliteration”
- Deflate at a rate of 2 mmHg/beat
Values:
Hypotension: Less than 90/60 mmHg
Normal: 120 /80
Hypertension: >140/90
Orthostatic Hypotension = drop of SBP by 20 mmHg from going from lying -> upright
Considerations:
- Ensure the cuff encircles approx 80% of the arm
- Cuff too LARGE = underestimates BP (not getting pressure back on the cuff
- Cuff to SMALL = overestimates BP (first pump = already exerting pressure
SpO2
Def & Locationn & Norms
Peripheral capillary oxygen saturation - how much O2 is there in the capillaries
Finger probe - Pulse Oximeter
Ear probe - indication: less visible, less likely to take it off (confused/aggitated pt)
Normal = 94% or above
Below 88% requires supplemental O2
Mechanism of Ventilation
(3)
Breathing Pattern
- Normal: Diaphragmatic >70%, lateral costal < 30%
- Distress or INC metabolic demand: Apical, Paradoxial, Flail Chest, use of abdominals to actively expire
Ratio of inspiration:expiration
- Normal: 1:2
- Obstructive disease: 1:3 or more
- Restrictive disease: 1:1
helps inform clinical reasoning
Depth:
- Shallow or normal
- Faster rate (get enough air into the lungs)
Types of Distressed Breathing
(5)
Apical: use of accessory mm
Paradoxical Breathing: reverse pattern of breathing
- INSPIRE: thoracic wall goes in chest wall (contracts)
- EXPIRE: chest wall expands
- Likely occurs because of trauma = MEDICAL EMERG
Flail Chest: likely rib fracture
- One segment gets sucked in d/t (-) pressure of throacic
Use of ABS to expire: pt w/ hyperinflation - to much air in the lungs
Thoracic Shape
(4)
Abnormal thoracic shape can affect mechanics of ventilation & V/Q mismatching (mostly affecting ventilation - ability to get ar in)
- Funnel Chest (pectus excavatum)
- Pigeon Chest (pectus carinatum)
- Kyphoscoliosis
Severe scoliosis - can affect CV system - Sx is indicated - Barrel Chest (AP: lateral = 1:1)
AP is as wide as ML - equally - d/t hyperinflation (throacic wall adapts & takes form)
“Increased lung compliance”
Head, Neck & Extremities
3 + 2 + 5
Head:
- Colour: palor (pale)
- Cyanosis: blue discolouration
Both colours are a result of hypoxemia > DEC O2 in circulatory system) > hypoxia > tissues lack O2
- Nasal flaring
Neck:
- Accessory mm use: hypertrophy (SCM), apical breathing
- Jugular vein distention: venous overload > conjestive heart failure (specificially RT)
Extremities:
- Capillary refill: peripheral perfusion ~2 sec
- Clubbing: raise in nailbed
Possible hypoxemia -> hypoxia
- Colour: palor
- Edema: peripheral - gravity dependent
Venous overload > conjestive heart failure (specificially RT)
- Muscle wasting: disuse (very fatiguing), hypoxia (mm does not get enough O2 adapts by getting smaller)
Cough, & Sputum
4 + 4
Cough:
- Effective (strength) - expel secretions/ mucus
- Productive
- Presistent (frequency): specific pathology
- Wet or dry - productive or not
Sputum:
- Quantity - how much
- Color
- Consistency - thickness
- Odor - few conditions that produce a foul odor
Sputum: DDx
7
Clear
1. Saliva
White
1. Normal (asthma)
Yellow
- Mucopurulent: Infected
1. Chronic bronchitis
2. Cystic Fibrosis (thick)
3. Pneumonia
Green - Purulent
1. Emphysema
2. Advanced pneumonia
3. Bronchiectasis - odor
4. Lung Abscess - odor
Brown flecks - carbon particles
1. Smoker
2. Smoke inhalation
Pink - frothy
1. Pulmonary edema - only condition
LT side heart failure > leads to pulmonary edema
Frank blood - Hemoptysis
- TB
- Lung cancer
- Pulmonary infarction
Components of PALPATION
(6)
1) Chest wall expansion
2) Diaphragmatic excursion
3) Edema
4) Pain & crepitus
5) Trachael Positioning
6) Tactile Fremitus
Chest Wall Expansion
Manual Method (subjective)
- Looking for amount of movement & symmetry between sides
- Assessment of 3 regions:
1. Upper lobes (sterno-costal)
2. Middle lobe & lingual (vertebro-costal)
3. Lower lobes (lateral costal ~T10)
Circumferential Method (objective)
- Uses measuring tape to measure the difference between full inhalation & full exhalation
- Common locations:
1. Axilla - common site
2. 10th rib
- Take 3 measurements & record best of 3
Manual = diagnostic
- ex. atelectasis - unilateral disease // fibrosis - bilateral disease (equally not moving)
Circum = baseline & tracking pro/regress
- Ex. AS - disease progression
Diaphragmatic Excursion
(3)
- Manual Method: hand placed on apex of belly during inspiration
- Circumferential Method: place take at level of apex of belly & instruct patient to first exhale & the maximally inhale
- Diaphragmatic percussions
Edema
2 Considerations & 4 Conditions
- Pitting vs non-pitting (severe lymphedema - skin is fibrotic)
- Level: how far up does it extend (foot - lower leg - thigh)
Conditions:
1. Right-sided Heart Failure
2. Lymphedema
3. Pregnancy
4. Systemic diseases
Pain & Crepitis
1 + 2
Pain
- Palpation producing INC pain can help differentiate between agina (referral pain would not be tender) d/t an organic nature or MSK pain
Crepitus
- Crepitus is a crunchy sound - like rice crispies
- When bubbles of air occur w/in subcutaneous tissue, a crackling sensation can be palpated (like bubble wrap/ rice krispies)
- Known as Subcutaneous emphysema (air under skin) - will get reabsorbed
In itself, is not dangerous BUT the reason why it is there is DANGEROUS
- Possible causes: air leak from chest tube, trauma, pneumothorax
Tracheal Positioning
3
The trachea should be between the sterno-costal joint
INC volume or pressure PUSHES the mediastinum away
CONTRALATERAL - high > low
- Ex. pneumothorax, pleural effusion, tumor/mass
DEC volume or pressure SHIFTS the mediastinum IPSILATERAL
- Less pressure so the lung will draw in - good lung is pushing it over
- Ex. atelectasis, pleural fibrosis, pnrumonextomy
UNILATERAL DISEASES
Tactile Fremitis
3
Therapist palpates with palm of hand or ulnar borders of hand for vibrations from sound transmission as patient loudly repeats “99”
INC sound transmission = more dense tissue
- ex. pneumonia - lots of consolidation (think & dense) = transmits more sound
DEC sound tranmission = less dense tissue
- ex. pleural effusion, pneumothorax - more air - air trapping
- Air: pillow effect - smothers the noise
- Effusion: fluid - also transmit sound poorly
Components of PERCUSSION
2
- Diagnostic Percussion
- Diaphragmatic Excursion
Diagnostic Percussion
Purpose & Specifics
Purpose is to determine the density of the underlying tissues
The sound produced from the percussion may assist in identifying normal & abnormal ventilation, as well as, detect change in lung density
Abnormality will only be detected up to 5cm in depth
- INC subcutaneous fat will not allow you to detect abnormality due to INC depth
** Same sites as ascultation
Percussion Sounds
- Resonant = normal aerated lung tissue
(air:tissue ratio normal)
Over normal tissue - Dull = non-aerated lung tissue OR thick tissue
(air:tissue ratio below normal)
Ex. Atelectasis, pneumonia, over ograns, tumor
** Atelectasis: tissue is folded together - ex rolling a tissue so it becomes thick tissue - Hyperresonant (tympanic) = over-aerated lung tissue = hyperinflated lung
(air:tissue ratio above normal)
Ex. COPD, pneumothorax, over empty stomach
Diaphragmatic Excursion
Measurubg diaphragmatic excursion with percussion
- Patient is asked to maximally exhale & hold > PT percusses down the same side of the chest wall (posteriorly & superior>inferior) from the point of the last marking > PT makes a marking when a dull sound if heard (diaphragm)
- Patient is asked to maxmially inhale & hold > PT repeats the procedure from the point of the last marking > Makes another point when dull sound is heard (diaphragm)
Normal = 3-5cm
DEC DE w/ hyperinflation + other conditions
Note: diaphragm sits higher on the RT (liver)
Components of AUSCULATION
(3)
- Breath Sounds
- Voice Sounds
- Heart Sounds - not studying
Stethoscope
(2)
Use bell for low frequency sounds - BP
Use diaphragm for high frequency sounds - pulmonary assessments (breath)
Breath Sounds
2 Types
Normal Breath Sounds:
1. Vesicular
2. Bronchovesicular
3. Bronchial
Abnormal Breath Sounds (Adventitia)
1. Crackles (rales)
2. Wheezes (rhonchi)
3. Pleural friction rub
4. Stridor
Vesicular
4
- Soft & low pitched
- I:E = 3:1
- Heard over peripheral lung tissue (entire lung except for ant & post areas over trachea & main stem bronchi
- Indicates normal lung
If DEC or absent, can indicate a pulmonary condition > atelectasis, COPD, pneumothorax, effusion
Bronchovesicular
(5)
- Mixture of bronchial & vesicular
- I:E = 1:1
- Inhalation = soft & low pitched
- Exhalation = loud & high pitched
- Heard over mainstem bronchi in 1st & 2nd intercostal spaces & posteriorly between the scaplae
Heard anywhere else is abnormal
Bronchial
- Loud, high-pitched, hollow quality
- Louder on exhalation
- I:E = 1:1 or 1:2
- Distinct pause between I & E
- Heard over trachea & manubrium
Heard over peripheral tissue = possible consolidation (ex pneumonia)
Crackles (rales)
Descrip & Class
Short & explosive
Classification:
Timing: inspiratory vs expiratory
Quality: coarse vs fine
- Coarse: usually sputum/secretions
- Fine: usually fluid (pulmonary edema) also head in atelectasis & fibrosis
Wheezing (rhonci)
Descrip & Class
Muscial
Can be affected by coughing
Class:
Ptich: high vs low - oscillation
- High: bronchial spasm
- Low: secretions in airway
Timing: inspiratory vs expiratory
Duration: short vs long
Notes: monophasic vs polyphonic
Pleural Friction (extrapulmonary sound)
Descrip (4)
Long, low-pitched, leathery creaking sound (sounds like stepping on fresh snow)
- Produced by frictional resistance between layers
- Pain may be associated with a pleural friction rub
- May be confused with pericardial rub from heart - to differentiate ask patient to hold their breath
If rub persist = pericardial rub (percarditis)
If rub dissapears = pleural friction
Associated with pleural effusion (but can be other things: cancer, pneumonia)
Stridor
Descrip
Loud, musical, high-constant pitch
- Audible from a distance w/o stethoscope
- Most prominent during inspiration
- Due to turbulent air flow (uper airway obstruction or narroawed airways
MEDICAL EMERGENCY - notify staff
Voice Sounds
Description + Techniques (3)
Voice sounds are produced as a result of a loss of selective filtering of high frequency sounds
** Only on technique is necessary as all 3 test for the same thing
Egophony
- Patient is asked to repeat the letter “E” as the therapist auscultates the chest wall
- If the letter “A” is heard during egophony (instead of “E”), it is an indication of consolidation (muscous or lung tissue - atelect)
E > A = (+) for consolidation
Whispered Pectoriloquy
- Whispered words change from muffled over noraml lung tissue to clear(er) over areas of consolidation
- INC in intensity & clarity of resonance = (+)
Hearing clearly - consolidation - trasmitting sound better
Fibrosis = (=) b/c of INC tissue density
Broncophony
- INC intensity and clarity of vocal resonance indicated consolidation
