Physical Examination Flashcards
What are the 5 things to Inspect (Inspection)
1) Vital Signs
2) Mode of Ventilation
3) Thoracic Shape
4) Head, Neck and extremities
5) Speech, cough and sputum
Vital signs (HR, BP, SPO2, RR)
HR:
Palpate radial pulse using INDEX finger and MIDDLE finge r
Pt remains quiet for 15s x 4 (total 60)
Bradycardia <60bpm
Normal: 60-100
Tachycardia: >100
**Neonates: 120-160 is normal
RR:
* inspect covertly
Bradypnea: <12breaths/min
Normal: 12-20b/min
Tachypnea: >20b/min
**Neonates: 40-60
BP
Normal
120/80
Hypertension >140/90
Hypotension <90/60
Orthostatic Hypotension - drop of >20SBPmmHg from lying to upright
SPO2
location: finger and ear probes
Normal 95-100%
Below 90% warrants further investigation
Define Mechanism of Ventilation (breathing pattern, Ratio of I:E, Depth)
Breathing Pattern
* Normal Diaphragmatic >70%, lateral Costal <30%
Distress or increased metabolic demand: Apical breathing (using scalene and SCM), paradoxical (inspiration chest recoils), Flail chest (multiple rib fracture sites where flail segments gt sucked in), abdominals used to actively expire
Ratio
Normal I:E = 1:2
Obstructive disease 1:3 or more
Restrictive 1:1
Depth: shallow or not
Thoracic Shapes (4)
- Funnel Chest: Pectus excavatum: sternum inwards
- Pectus carinatum (pigeon): sternum pokes forward
Kyphoscoliosis
Barrel chest AP:Lateral 1:1
Head, Neck and extremities
Head: color (pallor), Nasal Flaring, Cyanosis (lips)
Neck: Accessory muscle use/hypetrophy , Jugular vein Distension
Extremities: capillary refill - pinch nail bed takes 2s
Clubbing - schamroths window –> >180 dgerees
Colour - Pallor
Edema
Muscle wasting - not adqaute O2
Speech, cough, sputum
Cough: is it effective, productive, Persistent, Wet or dry?
Colour: white (normal), Yellow (mucuopurelent) (CB, CF, Pneumonia)
Green (purlent: possible infection - emphysema)
Pink frothy - Pulmonary edema
Frank blood - haemoptysis (TB, lung cancer, pulmonary infarction)
Palpation (6)
Chest wall expansion
Diaphragmatic excursion
Edema (pitting vs non-pitting)
Pain and crepitus
Tracheal positioning
Tactile fremitus
Manual vs circumferential method for chest wall expansion
Manual
1. upper lobes (sterno-costal)
2. Midde lobe and lingual (vertebrocostal) : on back side T4/T5
3. Lower lobes (lateral cstal) T10 region
Circumferential : tape measure - difference between full inhalation and full exhalation
Location: 1. Axilla, 10th rib
Tactile Fremitus
Palpates with palm of hand or ulnar borders of hand for vibrations from sound transmission as patient repeats “99”
Inreased sound transmission = more dense tissue or consolidaiton - IPF, pneumonia, Pulmonary edema, tumor
Decreased sound transmission = hyperinflation or increased distance between lung and chestwall
Percussion (2 types - diagnositc vs Diaphragmatic excursion)
Diagnostic
* determine density of underlying tissue
abnormality detected with 5cm in depth
Sounds
1. Resonant = Normal areated lung
2. Dull = Non-areated lung (air:tissue ratio is below normal)
3. Hyperresonant: hyperinflated lungs (COPD, pneumothorax, over empty stomach)
Breath-sounds
Normal Vs abnormal
Normal
1. Vesicular (peripheral tissue, I:E = 3:1)
2. Bronchovesicular (main stem bronchi, inspiration soft low pitches and expiration is loud high pitches, I:E = 1:1
3. Bronchial (heard over trachea and manubrium, Loud high pitched, hollow, I:E = 1:1)
Abnormal
- Crackles
-Wheezes
-Pleaural Frction rub
- Stridor
Crackles Fine vs Coarse
Course - air moving over retained secretions, causing opoening and closing of airways
heard on inspiration and expiraiton - it is wet
Fine: Often heard in inspiration, popping open of closed alveoli - dry - usually basal
Describe wheeze
Pleural friction rub
Stridor
Musical
Monophonic: one note - means there is one obstruction most likely tumor
Polyphonic: multiple different notes- asthma
PFR
- long- low pitches, leathery creaking sound
- friction resistance between layers
pain associated
**confused with pericardial rub - ask patient to hold breatha nd if sound is there it is from heart
Stridor
- Loud and musical
- Audible from distance
- Large obstruction of the upper airway
