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Cardiorespiratory > Physical Examination > Flashcards

Physical Examination Flashcards

1
Q

Componenets of INSPECTION

(5)

A
  1. Vital Signs
  2. Mechanism of Ventilation
  3. Throacic Shape
  4. Head, Neck, & Extremities
  5. Speech, cough, & sputum
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2
Q

Vital Sign: Components of Assessment

A
  1. Heart Rate
  2. Respiratory Rate
  3. Blood Pressure
  4. SpO2
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3
Q

Heart Rate

Rate & Rhythm

A

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)

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4
Q

Respiratory Rate (RR)

Rate - Adults & Babies

A

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

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5
Q

Blood Pressure

Procedure Details & Values & Consideration

A

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

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6
Q

SpO2

Def & Locationn & Norms

A

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

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7
Q

Mechanism of Ventilation

(3)

A

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)

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8
Q

Types of Distressed Breathing

(5)

A

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

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9
Q

Thoracic Shape

(4)

A

Abnormal thoracic shape can affect mechanics of ventilation & V/Q mismatching (mostly affecting ventilation - ability to get ar in)

  1. Funnel Chest (pectus excavatum)
  2. Pigeon Chest (pectus carinatum)
  3. Kyphoscoliosis
    Severe scoliosis - can affect CV system - Sx is indicated
  4. Barrel Chest (AP: lateral = 1:1)
    AP is as wide as ML - equally - d/t hyperinflation (throacic wall adapts & takes form)
    “Increased lung compliance”
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10
Q

Head, Neck & Extremities

3 + 2 + 5

A

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)

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11
Q

Cough, & Sputum

4 + 4

A

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

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12
Q

Sputum: DDx

7

A

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

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13
Q

Components of PALPATION

(6)

A

1) Chest wall expansion
2) Diaphragmatic excursion
3) Edema
4) Pain & crepitus
5) Trachael Positioning
6) Tactile Fremitus

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14
Q

Chest Wall Expansion

A

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

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15
Q

Diaphragmatic Excursion

(3)

A
  1. Manual Method: hand placed on apex of belly during inspiration
  2. Circumferential Method: place take at level of apex of belly & instruct patient to first exhale & the maximally inhale
  3. Diaphragmatic percussions
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16
Q

Edema

2 Considerations & 4 Conditions

A
  • 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

17
Q

Pain & Crepitis

1 + 2

A

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

18
Q

Tracheal Positioning

3

A

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

19
Q

Tactile Fremitis

3

A

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

20
Q

Components of PERCUSSION

2

A
  1. Diagnostic Percussion
  2. Diaphragmatic Excursion
21
Q

Diagnostic Percussion

Purpose & Specifics

A

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

22
Q

Percussion Sounds

A
  1. Resonant = normal aerated lung tissue
    (air:tissue ratio normal)
    Over normal tissue
  2. 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
  3. Hyperresonant (tympanic) = over-aerated lung tissue = hyperinflated lung
    (air:tissue ratio above normal)
    Ex. COPD, pneumothorax, over empty stomach
23
Q

Diaphragmatic Excursion

A

Measurubg diaphragmatic excursion with percussion

  1. 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)
  2. 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)

24
Q

Components of AUSCULATION

(3)

A
  1. Breath Sounds
  2. Voice Sounds
  3. Heart Sounds - not studying
25
Q

Stethoscope

(2)

A

Use bell for low frequency sounds - BP
Use diaphragm for high frequency sounds - pulmonary assessments (breath)

26
Q

Breath Sounds

2 Types

A

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

27
Q

Vesicular

4

A
  • 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

28
Q

Bronchovesicular

(5)

A
  • 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
29
Q

Bronchial

A
  • 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)
30
Q

Crackles (rales)

Descrip & Class

A

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

31
Q

Wheezing (rhonci)

Descrip & Class

A

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

32
Q

Pleural Friction (extrapulmonary sound)

Descrip (4)

A

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)

33
Q

Stridor

Descrip

A

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

34
Q

Voice Sounds

Description + Techniques (3)

A

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

Cardiorespiratory (13 decks)

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