Physical Examination of the Patient

Question 1

Describe Peripheral Edema and what it entails

Answer 1

1. Presence of excessive fluid in the tissue known as pitting edema
2. Occurs primarily in arms and ankles
3. Caused by CHF and renal failure
4. Rated +1, +2, +3, etc. The higher the number, the greater the swelling.
5. Recommend diuretic therapy.

Question 2

Ascites

Answer 2

accumulation of fluid in the abdomen generally caused by liver failure

Question 3

Capillary Refill

Answer 3

Indication of peripheral circulation.

a. Blanching the hand and watch for color to return.
b. Color should return within 3 seconds

Question 4

Skin Color

Answer 4

a. Decrease in color (ashen, pallor) due to anemia or acute blood loss (Vasoconstriction will cause this change in color by reducing blood flow)
b. Jaundice - increased bilirubin level in blood and tissue. Appears mostly in the face and trunk.
c. Erythema - redness of the skin. May be caused by capillary congestion, inflammation, or infection
d. Cyanosis - blue or blue-gray (dusky) discoloration of skin and/or mucous membranes. Caused by hypoxia.

Question 5

Restrictive Chest Configurations (3)

Answer 5

1. Pectus Carinatum - anterior protrusion of the sternum
2. Pectus Excavatum - depression of part of or the entire sternum
3. Kyphosis - convex curvature of the spine (lean forward)

Question 6

Eupnea

Answer 6

Normal respiratory rate, depth, and rhythm.

NORMAL RR for adults is 12 - 20 breaths/min

Question 7

Hyperpnea

Answer 7

Increased RR, increased depth, normal rhythm

Cause: Metabolic disorder/CNS disorders

Question 8

Cheyne-Stokes

Answer 8

Gradually increasing then decreasing rate and depth in a cycle lasting from 30-180 seconds, with periods of apnea lasting up to 60 seconds
Cause: increased ICP, brainstem injury, drug overdose

Question 9

Biot’s

Answer 9

Increased RR and depth with irregular periods of apnea. Each breath has the same depth.
Cause: CNS problem

Question 10

Kussmaul’s

Answer 10

Increased RR, increased depth, irregular rhythm, breathing sounds labored
Cause: hypoxemia, metabolic acidosis, renal failure, diabetic ketoacidosis

Question 11

Apneustic

Answer 11

Prolonged gasping inspiration followed by extremely short, insufficient expiration.
Cause: problem with respiratory center, trauma, or tumor

Question 12

Hypopnea

Answer 12

Shallow or slow breathing

Question 13

Retractions

Answer 13

Intercostal and/or sternal retractions occur when the chest moves inward during inspiratory efforts instead of outward.
Adult: airway obstruction
Newborn: respiratory distress (nasal flaring most common sign)

Question 14

Mallampati Classification (four classes)

Answer 14

Class I: Soft palate, uvula, fauces, pillars visible
Class II: Soft palate, uvula, fauces visible
Class III: Soft palate and base of uvula visible
Class IV: Only hard palate visible.

(Class III and IV are considered difficult airways)

Question 15

NORMAL pulse rate (adult)

Answer 15

60 - 100/minute

Question 16

Recommended treatment for Tachycardia?

Answer 16

oxygen therapy

Question 17

Recommended treatment for Bradycardia?

Answer 17

Atropine (bradycardia suggests heart failure, shock, code/emergency)

Question 18

A change in heart rate of __________ is an adverse reaction.

Answer 18

20 beats/min. Stop therapy, notify nurse or doctor, and record event.

Question 19

Paradoxical pulse/pulsus paradoxus

Answer 19

Pulse/blood pressure varies with respiration. May indicate severe air trapping (status asthmaticus, tension pneumothorax, cardiac tamponade).

Question 20

Tracheal deviation toward normal side (away from pathology) indicates

Answer 20

Problem is outside of the lung in the pleural space.

1. Massive pleural effusion
2. Tension pneumothorax
3. Neck or thyroid tumors
4. Large mediastinal mass

Question 21

Diagnostic Chest Percussion

Resonant
Tympanic

Answer 21

• Normal, air-filled lung

- Normally heard over air-filled stomach

Question 22

Vesicular

Answer 22

Normal breath sounds

Question 23

Bronchial Breath Sounds

Answer 23

Normal sounds heard over the trachea or bronchi. These breath sounds over the lung periphery would indicate lung consolidation.

Question 24

Egophany

Answer 24

The patient is instructed to say “E” and it sounds like “A”. Indicates consolidation.

Question 25

Adventitious

Answer 25

Abnormal breath sounds

Question 26

Crackles/rales

Answer 26

Secretion/fluid.

• Coarse: instruct patient to cough or suction patient
• Medium: recommend bronchial hygiene (CPT)
• Fine: associated with CHF/pulmonary edema. Recommend oxygen, PPT, positive inotropic agents (heart strengthening agents), diuretics

Question 27

Unilateral wheeze indicates

Answer 27

Foreign body obstruction. Recommend RIGID bronchoscopy.

Question 28

Stridor

Answer 28

High-pitched or crowing inspiratory sound caused by upper airway obstruction.
a. Supraglottic swelling (epiglottitis)
b. Subglottic swelling (croup, post extubation)
Treat with topical decongestant (racemic epinephrine)
If “marked” stridor - intubate!

Question 29

Stertor

Answer 29

Noisy breathing that occurs during inhalation. Snoring.

Question 30

Pleural friction rub

Answer 30

Coarse, grating raspy or crunching sound caused by inflamed surface of the visceral and parietal pleura rubbing together.
May be associated with pleurisy, TB, pneumonia, pulmonary infarction, cancer, etc.
Recommend steroids and antibiotics.

Question 31

Normal Heart Sounds

Answer 31

• Sounds created by the closure of heart valves
• First sound (S1) created by normal closure of the mitral and tricuspid valves at the beginning of ventricular contraction.
• Second sound (S2) is normal and occurs when systole ends. The ventricles relax and the pulmonic and aortic valves close.

Question 32

Abnormal heart sounds and what they suggest

Answer 32

S3: In an adult, the presence of S3 may suggest heart failure.
S4: The presence of a fourth sound is indicative of a cardiac abnormality such as uncontrolled hypertension or aortic stenosis.
Recommend echocardiogram.

Question 33

NORMAL blood pressure value (ADULT) and acceptable range

Answer 33

120/80 mm Hg

Systolic: 90 - 140 mm Hg
Diastolic: 60 - 90 mm Hg