Chapter 5. Fundamentals of Physical Examination.pdf

FUNDAMENTALS OF PHYSICAL EXAMINATION Chapter 5 EXAMINATION OF THE HEAD AND NECK FACIAL EXPRESSION Identify patient’s facial expression Acute distress Pain Alertness, mood, mental capacity  Signs of Respiratory Disease: Nas...

FUNDAMENTALS OF PHYSICAL EXAMINATION Chapter 5 EXAMINATION OF THE HEAD AND NECK FACIAL EXPRESSION Identify patient’s facial expression Acute distress Pain Alertness, mood, mental capacity  Signs of Respiratory Disease: Nasal flaring NASAL Flaring of the nares during inspiration Suggests an increased WOB is present FLARING AND Cyanosis Bluish discoloration of the skin CYANOSIS Only apparent when a significant amount of deoxygenated Hb is present NASAL FLARING AND PERIPHERAL CYANOSIS CENTRAL CYANOSIS More severe Lips, nose, ears, neck region, tongue Darker pigmentation more difficult to see ACROCYANOSIS ACROCYANOSIS PURSED-LIP BREATHING Commonly seen in patient’s with COPD Technique taught to patients Pucker lips during exhalation EYES http://tbn0.google.com/images?q=tbn:q46FZ9kJXZireM:http://upload.wikimedia.org/wikipedia/commons/thumb Evaluated as part of mydriasis the neurologic exam PERRLA Mydriasis dilated and fixed miosis Miosis pinpoint pupils EYES Ptosis: drooping upper lid Diplopia: double vision Nystagmus NECK Inspection and palpation used to determine: tracheal position JVP (jugular venous pressure) Accessory muscle use Tracheal shift Away from affected side Tension pneumothorax, pleural effusion, To affected side Atelectasis, lung resection PNEUMOTHORAX JVP Estimated by examining the level of the column of blood in the jugular veins Jugular Veins are full in a supine position At a 45º angle, the column of blood descends to few cm above clavicle Measure the distance veins are distended above sternal angle  Changes with breathing Most common cause is right heart failure Other causes: Hypervolemia Obstruction of venous return to the R atrium JVP LUNG TOPOGRAPHY ANTERIOR Midsternal line Midclavicular lines Midaxillary line Anterior axillary line IMAGINARY Posterior axillary line LINES POSTERIOR Midspinal line Midscapular lines THORACIC CAGE LANDMARKS  Suprasternal notch  Sternal angle or angle of Louis  Ribs SUPRASTERNAL NOTCH THORACIC CAGE LANDMARKS POSTERIOR  Spinous processes of vertebrae  Most prominent spinous process at the base of the neck  C7 spinous process  Scapular borders. LUNG FISSURES Interlobar fissures: Oblique fissure Right and left lung Horizontal fissure Right lung LUNG FISSURES LUNG FISSURES  Tracheal Bifurcation: Carina Approximately T4 Diaphragm LANDMARKS Right dome Anterior: 5th rib Posterior: T9 Left dome Anterior: 6th rib Posterior: T10 TRACHEAL BIFURCATION (CARINA) Anterior chest: beneath the sternal angle Posterior chest: T4 TRACHEAL BIFURCATION Tracheal Bifurcation DIAPHRAGM At end-exhalation:  R dome is at:  5th rib anteriorly  T9 posteriorly  L dome is at:  6th rib anteriorly  T10 posteriorly. R hemidiaphragm higher than left -- liver LUNG BORDERS Superior: 2-4 cm above clavicles Inferior: extend to 6th rib midclavicular line Lateral wall: 8th rib LUNG BORDERS  Superior borders: T1  Inferior borders: T9-T12 PLEURAL SPACE EXAMINATION OF THE THORAX Chapter 5: Part 2  AP diameter < transverse diameter Barrel Chest Common in patients with emphysema (COPD) INSPECTION Other abnormalities: Pectus carinatum Pectus excavatum Kyphosis Scoliosis Kyphoscoliosis Flail chest THORACIC CONFIGURATION SCOLIOSIS KYPHOSIS KYPHOSIS KYPHOSCOLIOSIS FLAIL CHEST  Normal: minimal effort on inspiration and passive exhalation Accessory muscles Slightly active during normal inspiration at rest Become more active as ventilatory demands increase BREATHING Sternocleidomastoid muscle use indicative of severe obstruction Retractions PATTERN AND Restrictive lung disease EFFORT Acute obstruction of intrathoracic airways Asthma Prolonged expiratory time Acute upper airway obstruction Croup or epiglottitis Prolonged inspiratory time ACCESSORY MUSCLES ACCESSORY MUSCLES RETRACTIONS  Apnea Cessation of breathing Biot Irregular breathing with long periods of apnea ABNORMAL Cheyne-Stokes Increase and decrease on depth and rate with periods of apnea BREATHING Kussmaul Deep and fast PATTERNS Apneustic prolonged inhalation Paradoxic inward movement during inspiration BREATHING PATTERNS PALPATION Act of touching the chest wall to evaluate underlying lung structure and function Used to confirm or rule out suspected problems with history and physical exam Vocal fremitus Vibrations created by the vocal cords during phonation Tactile fremitus During palpation the patient is asked to repeat “99” Palmar aspect of fingers or ulnar aspect of hand  Increased Transmission of vibration through a more solid medium VOCAL If consolidation or high density area is not FREMITUS in connection with patent airway, fremitus will be decreased or absent  Decreased Unilateral Bronchial obstruction Pneumothorax Pleural effusion VOCAL Diffuse COPD (hyperinflated lung) FREMITUS Obese chest wall Muscular chest wall Rhonchial fremitus Vibrations produced by passage of air through thick secretions May clear after cough THORACIC EXPANSION Normal chest wall expands symmetrically during deep inspiration Posterior access T8 Deep inspiration each thumb moves approximately 3 to 5 cm from midline Abnormal expansion Bilateral Unilateral  Subcutaneous emphysema: air pockets palpable on skin when air leak from the lung is present SKIN AND SUBCUTANEOUS TISSUE AUSCULTATION OF THE LUNGS STETHOSCOPE 4 basic parts: Bell: light placement Diaphragm: firm placement Tubing: approx. 19 inches Earpieces Check regularly for cracks in diaphragm and tubing. Disinfect between patients  Relaxed sitting upright position Breath a little deeper than normal through mouth Diaphragm placed directly against the chest Tubing should touch anything while auscultating Systematic placement on chest TECHNIQUE TECHNIQUE  4 Lung sound characteristics Pitch Amplitude Distinctive characteristics Duration of inspiration vs. expiration BREATH SOUNDS RESPIRATORY CYCLE TERMINOLOGY Tracheal Vesicular Harsh Bronchial Adventitious CHARACTERISTICS OF LUNG SOUNDS  SOUNDS DURING BREATHING LOCATION OF NORMAL LUNG SOUNDS NORMAL LUNG SOUNDS TERMINOLOGY Adventitious Continuous Discontinous Crackles (rales) Early vs Late Wheeze Rhonchi Stridor Pleural friction rub LATE INSPIRATORY CRACKLES WHEEZING PLEURAL FRICTION RUB  Normal air filled lungs filter voice sounds VOICE This reduces intensity and clarity SOUNDS Bronchophony Whispered Pectoriloquy Egophony BRONCHOPHONY EXTREMITY EXAMINATION CLUBBING PEDAL EDEMA Pedal Edema PERIPHERAL SKIN TEMP Palpation of a patient’s hands and feet may provide general information about perfusion Compare patient’s extremities with room temp Poor peripheral perfusion cool extremities CAPILLARY REFILL