Pulmonary Assessment Sheet PDF

 THE TOP FIVE BENEFITS OF A RESPIRATORY ASSESSMENT: 1. EARLY DETECTION OF RESPIRATORY CONDITIONS 2. INDIVIDUALIZED TREATMENT PLANS 3. IMPROVED SYMPTOM MANAGEMENT 4. PREVENTION AND EDUCATION 5. LONG-TERM RESPIRATORY HEALTH MONITORING  MAIN COMPONENTS...

 THE TOP FIVE BENEFITS OF A RESPIRATORY ASSESSMENT: 1. EARLY DETECTION OF RESPIRATORY CONDITIONS 2. INDIVIDUALIZED TREATMENT PLANS 3. IMPROVED SYMPTOM MANAGEMENT 4. PREVENTION AND EDUCATION 5. LONG-TERM RESPIRATORY HEALTH MONITORING  MAIN COMPONENTS OF PULMONARY ASSESSMENT SHEET: PROCEDURE BEFORE INITIATION OF ASSESSMENT SESSION WASH YOUR HANDS. INTRODUCE YOURSELF TO THE PATIENT INCLUDING YOUR NAME AND ROLE. CONFIRM THE PATIENT’S NAME AND DATE OF BIRTH. EXPLAIN THAT YOU’D LIKE TO TAKE A HISTORY FROM THE PATIENT. GAIN CONSENT TO PROCEED WITH HISTORY TAKING. SOME GENERAL COMMUNICATION SKILLS WHICH APPLY TO ALL PATIENT CONSULTATIONS INCLUDE DEMONSTRATING EMPATHY ACTIVE LISTENING: THROUGH BODY LANGUAGE AND YOUR VERBAL RESPONSES AN APPROPRIATE LEVEL OF EYE CONTACT. OPEN, RELAXED, YET PROFESSIONAL BODY LANGUAGE DO NOT TO INTERRUPT THE PATIENT THROUGHOUT THE CONSULTATION. ESTABLISHING RAPPORT SIGNPOSTING SUMMARISING AT REGULAR INTERVALS.  1-HISTORY TAKING HISTORY TAKING CAN BE DIVIDED TO : 1-PERSONAL HISTORY: INCLUDES PATIENT’S NAME, AGE, SEX, OCCUPATION, MARITAL STATUS  2-SOCIAL HISTORY THE TYPE OF ACCOMMODATION THEY CURRENTLY RESIDE IN SMOKING HISTORY, INCLUDING THE TYPE AND AMOUNT OF TOBACCO USED ALCOHOL CONSUMPTION: RECORD THE FREQUENCY, TYPE AND VOLUME OF ALCOHOL CONSUMED ON A WEEKLY BASIS RECREATIONAL DRUGS USE AND IF SO DETERMINE THE TYPE OF DRUGS USED AND THEIR FREQUENCY OF US EXERCISE ASK IF THE PATIENT REGULARLY EXERCISES (INCLUDING FREQUENCY AND EXERCISE TYPE CURRENT AND PREVIOUS TO IDENTIFY POTENTIAL EXPOSURE TO AGENTS WHICH CAN LEAD TO RESPIRATORY DISEASE: COAL MINING (PNEUMOCONIOSIS) FARMERS (ALLERGIC EXTRINSIC ALVEOLITIS) THOSE WORKING IN SHIPYARDS, CONSTRUCTION AND PLUMBING (MESOTHELIOMA)  3-FAMILY HISTORY ASK THE PATIENT IF THERE IS ANY FAMILY HISTORY OF RESPIRATORY DISEASE (E.G. ASTHMA, ECZEMA, CYSTIC FIBROSIS, LUNG CANCER)  4-MEDICAL HISTORY: PAST MEDICAL HISTORY (DIABETES , HYPERTENSION, CARDIAC DISORDERS,(DVT) SURGERY OR PROCEDURES (LOBECTOMY , BRONCHOSCOPY) IMMUNIZATION HISTORY (INFLUENZA, PNEUMOCOCCUS, COVID-19, TUBERCULOSIS) ALLERGIES (E.G. MILD RASH VS ANAPHYLAXIS). DRUG HISTORY: (MEDICATION NAME, DOSE, FREQUENCY,) ANY SIDE EFFECTS FROM THEIR MEDICATION (E.G. DRY COUGH WITH ACE INHIBITOR OVER THE COUNTER DRUGS (ASPIRIN (MAY WORSEN HEMOPTYSIS IF ALREADY PRESENT)  SYSTEMIC ENQUIRY SYSTEMIC: FEVERS, WEIGHT CHANGE, FATIGUE CARDIOVASCULAR: CHEST PAIN, PALPITATIONS, OEDEMA, SYNCOPE, ORTHOPNEA GASTROINTESTINAL: NAUSEA, VOMITING, DYSPHAGIA, ABDOMINAL PAIN GENITOURINARY: OLIGURIA, POLYURIA NEUROLOGICAL: VISUAL CHANGES, MOTOR OR SENSORY DISTURBANCES, HEADACHE, CONFUSION MUSCULOSKELETAL: CHEST WALL PAIN, TRAUMA DERMATOLOGICAL: RASHES  HISTORY OF PRESENTING COMPLAINT (PRESENT HISTORY) 1-COUGH REFLEX ACT OF FORCEFUL EXPIRATION AGAINST A CLOSED GLOTTIS GENERATING POSITIVE INTRATHORACIC PRESSURE AS HIGH AS 300 MM HG. AIM IS TO CLEAR THE AIRWAYS  CLASSIFICATION OF COUGH: 1-ACUTE COUGH (8 WKS. TUBERCULOSIS, BRONCHIAL ASTHMA, COPD, BRONCHOGENIC CARCINOMA  TYPES OF COUGH: 1. WET COUGH (PRODUCTIVE COUGH) WITH MUCUS MAY BE ACUTE OR CHRONIC IN COLD FLUE, ASHMA 2. DRY COUGH (NONPRODUCTIVE COUGH) LIKE A TICKLE IN BACK OF THROAT, NO MUCUS, MAY LAST SEVERAL WEEKS AFETER END OF FLU IN ASHMA, ALLERGIES 3. PAROXYSMAL COUGH (WHOOPING COUGH) VIOLENT, EXHAUSTING, PAINFUL COUGH CAUSE BREATHLESSNESS & VOMITING 4. CROUP COUGH FROM VIRAL INFECTION CAUSE IRRITATION AND SWELLING IN UPPER AIRWAYS & RASPY VOICE,SQUEAKY BREATHING AFFECT CHILDREN & CONTAGIOUS FOR 3 DAYS  2-SPUTUM SPUTUM IS MUCUS THAT IS COUGHED UP FROM THE LOWER AIRWAYS (THE TRACHEA AND BRONCHI) MECHANISM OF MUCUS SECRETION: MUCUS-SECRETING CELLS: GOBLET CELLS OF THE MUCOUS MEMBRANES AND THE SUBMUCOSAL GLANDS OF THE RESPIRATORY, GI, AND REPRODUCTIVE SYSTEMS ARE RESPONSIBLE FOR THE SECRETION OF MUCUS THE MUCO-CILIARY ESCALATOR: RESPONSIBLE FOR THE CLEARANCE OF MUCUS TOWARDS THE PHARYNX, & EXPECTORATED WITH COUGH REFLEX  CONSISTENCY 1. SEROUS (CLEAR &WATERY) - UPPER RESPIRATORY TRACT INFECTION, BRONCHOALVELOLAR CARCINOMA 2. MUCOID - CHRONIC BRONCHITIS, BRONCHIAL ASTHMA 3. MUCOPURULENT (THICKER & OBIQUE) - BACTERIAL INFECTION  AMOUNT OF SPUTUM VARIES FROM TEASPOON AMOUNT THE 5 ML LINE TO PLASTIC CUP AMOUNT COPIOUS AMOUNTS FOUND IN 1. BRONCHIECTASIS 2. LUNG ABSCESS 3. NECROTIZING PNEUMONIA 4. ALVEOLAR CELL CARCINOMA  COLOR OF SPUTUM: YELLOW / GREEN — BACTERIAL INFECTION BLACK — COAL WORKER PNEUMOCONIOSIS PINK FROTHY SPUTUM — PULMONARY EDEMA RUSTY SPUTUM- PNEUMOCOCCAL PNEUMONIA RED CURRANT JELLY SPUTUM- KLEBSIELLA BLOOD TINGED / STREAKING OF SPUTUM- TUBERCULOSIS ANCHOVY SAUCE — RUPTURED AMOEBIC LIVER ABSCESS  SPUTUM SMELL: FOUL SMELL PRESENT IN LUNG ABSCESS, BRONCHIECTASIS, ANAEROBIC BACTERIAL INFECTION  3-DYSPNEA: MEDICAL TERM DESCRIBES DIFFICULTY BREATHING OR SHORTNESS OF BREATH MAY RANGE FROM MILD AND TEMPORARY TO SERIOUS AND LONG LASTING GRADING OF DYSPNEA (MODIFIED MEDICAL RESEARCH COUNCIL (MMRC SCALE) Grade Description of breathlessness 0 I only get breathless with strenuous exercise 1 I get short of breath when hurrying on level ground or walking up a slight hill 2 On level ground, I walk slower than people of the same age because of breathlessness, or have to stop for breath when walking at my own pace 3 I stop for breath after walking about 100 yards [91 meters] or after a few minutes on level ground 4 I am too breathless to leave the house or I am breathless when dressing  ONSET WITHIN MINUTES PNEUMOTHORAX, PULMONARY EMBOLISM, INHALATION OF FOREIGN BODY, LARYNGEAL EDEMA HOURS TO DAYS: ACUTE RESPIRATORY DISTRESS SYNDROME, BRONCHIAL ASTHMA, PNEUMONIA, LEFT HEART FAILURE WEEKS TO MONTHS: COPD, PLEURAL EFFUSION, ANEMIA, THYROTOXICOSIS RELIEVING FACTORS AGGRAVATING FACTORS MEDICATION EXPOSURE TO ALLERGEN REST EXERCISE REMOVAL OF ALLERGEN DRUGS COLD WHETHER  HEMOPTYSIS: IS THE DISCHARGE OF BLOOD OR BLOOD-STAINED MUCUS THROUGH THE MOUTH COMING FROM THE BRONCHI, LARYNX, TRACHEA, OR LUNGS  TYPES OF HEMOPTYSIS: FRANK- EXPECTORATION OF BLOOD ONLY SPURIOUSS: ECONDARY TO UPPER RESPIRATORY TRACT INFECTION ABOVE THE LEVEL OF LARYNX PSEUDO HEMOPTYSIS: DUE TO PIGMENT PRODUCED BY GRAM NEGATIVE BACTERIA SEVERITY MILD 600ML /DAY OR 100ML/DAY FOR MORE THAN 3 DAYS OR 150 ML/HR CAUSES OF HEMOPTYSIS: 1-INFECTIOUS: ( TB, LUNG ABSCESS, BRONCHIECTASIS, PNEUMONIA, FUNGAL INFECTION (ASPERGILLOSIS BLASTOMYCOSIS) 2-NEOPLASM: (BRONCHOGENIC CARCINOMA , BRONCHIAL ADENOMA, METASTATIC TUMOR 3-CARDIOVASCULAR DISORDERS: (PULMONARY EMBOLISM, AV MALFORMATION)  5-CHEST PAIN: ASK ABOUT (SITE, ONSET, DURATION, SEVERITY, CHARACTER, RADIATION, ASSOCIATED SYMPTOMS, AGGRAVATING/RELIEVING FACTOR, DIURNAL /SEASONAL VARIATION, RETROSTERNAL PAIN)  CAUSES: UPPER CHEST: TRACHEAITIS MID AND LOWER CHEST( MEDIASTINITIS- MEDIASTINAL TUMOR- GERD- ACHALASIA CARDIA) DIFFUSE ESOPHAGEAL SPASM PLEURAL INFLAMMATION –(CATCHY PAIN, INCREASES ON DEEP INSPIRATION AND ON PRESSURE IS STABBING IN CHARACTER) PANCOAST TUMOR– SHOULDER AND ARM PAIN DUE TO COMPRESSION OF C8, T1-2 ROOTS IS SHARP SHOOTING PAIN ALONG THE COURSE OF NERVE. EROSION OF RIBS – CONSTANT DULL ACHING CHEST PAIN. TIETZE’S SYNDROME – COSTOCHONDRITIS(USUALLY 2ND COSTOCHONDRAL JUNCTION), UNKNOWN ETIOLOGY.  THE MNEMONIC OPQRSTU: (MORTON, 1993) O: ONSET OF ILLNESS OR OTHER — ARE THE PATIENT’S FAMILY OR FRIENDS UNWELL? P: PROVOCATIVE OR PALLIATIVE — WHAT MAKES THE SYMPTOMS WORSE OR BETTER? Q: QUALITY AND QUANTITY OF THE PAIN OR SYMPTOM — WHAT TYPE OF PAIN AND HOW MUCH? R: RADIATION OF THE PAIN — SYMPTOM OR REGION S: SEVERITY — ON A SCALE OF 1–10, WITH 10 REPRESENTING THE ‘WORST PAIN IMAGINABLE’ T: TIMING — HAS THE PATIENT HAD THIS SYMPTOM BEFORE, AND WHAT TIME OF THE DAY OR NIGHT DOES IT WORSEN? U (YOU): WHAT IS THE PATIENT’S PERCEPTION OF THEIR SYMPTOMS?  B-CLINICAL EXAMINATION: 1-INSPECTION: A-GENERAL INSPECTION: B- LOCAL INSPECTION  CLOUDING OF CONSCIOUSNESS GENERAL INSPECTION INATTENTION & REDUCED WAKEFULLNESS 1-CONCIOUSNESS: CONFUSIONAL STATE DISORIENTATION & DIFFICULTY FOLLOW ORDERS LETHARGY PATIENT CAN BE AROUSED BY MODERATE STIMULI AND THEN DRIFT BACK TO SLEEP. OBTUNDATION SLOWED RESPONSES TO STIMULATION, AND TENDS TO SLEEP MORE THAN NORMAL STUPOR ONLY VIGOROUS AND REPEATED STIMULI WILL AROUSE THE INDIVIDUAL COMA UNAROUSABLE UNRESPONSIVENESS  GLASGOW COMA SCALE (GCS) 1-EYE-OPENING (1-4 2-VERBAL RESPONSE (1-5 3-MOTOR ACTIVITY (1-6 POINTS) POINTS) POINTS) MAKES NO MOVEMENTS. DOES NOT OPEN EYES IN RESPONSE TO MAKES NO SOUNDS. 1 DECEREBRATE (EXTENSOR) POSTURE (AN ABNORMAL ANYTHING. 1 INCOMPREHENSIBLE SOUNDS. 2 POSTURE THAT CAN INCLUDE RIGIDITY, ARMS AND LEGS OPENS EYES IN RESPONSE TO PAINFUL HELD STRAIGHT OUT, TOES POINTED DOWNWARD, HEAD AND UTTERS INCOHERENT WORDS. 3 NECK ARCHED BACKWARD). STIMULI. 2 CONFUSED, DISORIENTED. 4 DECORTICATE (FLEXOR) POSTURE (AN ABNORMAL POSTURE OPENS EYES IN RESPONSE TO VOICE. 3 THAT CAN INCLUDE RIGIDITY, CLENCHED FISTS, LEGS HELD ORIENTED, CONVERSES NORMALLY. 5 STRAIGHT OUT, AND ARMS BENT INWARD TOWARD THE OPENS EYES SPONTANEOUSLY. 4 BODY WITH THE WRISTS AND FINGERS BEND AND HELD ON THE CHEST). WITHDRAWAL FROM PAINFUL STIMULI. LOCALIZES TO PAINFUL STIMULI. OBEYS COMMANDS. EXAMPLE: SO A PATIENT WHO HAS SCORES OF EYE = 3, VERBAL = 4 AND MOTOR = 5 IS SAID TO HAVE A GCS OF 12. YOU WOULD EXPRESS THIS AS A GCS 12 = E3, V4, M5.  CONT. GENERAL INSPECTION 2-AGITATION & ANXIETY 3-SPEECH (SENTENCES/ PHRASES/ WORDS/ UNABLE TO SPEAK) QUALITY OF SPEECH (LOUD, CLEAR, HOARSENESS OF VOICE 4-BODY TYPE OBESE, NORMAL, CACHECTIC) 5-LEVEL OF DISTRESS CARDIAC: CHEST DISCOMFORT, DYSPNEA, LIGHTHEADEDNESS, OR DIZZINESS PULMONARY: USE OF ACCESSORY MUSCLES, PURSED-LIP BREATHING, SPEECH INTERRUPTED TO TAKE BREATHS  6-SKIN COLOR PALLOR : AN UNUSUAL LOSS OF COLOR, OR PALENESS, IN THE SKIN (E.G., THE FACE) CAUSES INCLUDE (ANEMIA- SHOCK- STRESS- ANXIETY) TREATMENT: 1- CONSUMING A DIET THAT IS RICH IN VITAMINS B, C, AND D, IRON, PROTEIN, AND FIBER 2- GETTING PLENTY OF REST 3- TAKING THE PROPER MEDICATION: 4- ENCOURAGING HEALTHY BLOOD CIRCULATION, EXERCISING REGULARLY, AVOIDING SMOKING AND TOBACCO, AND ALCOHOL. KEEP YOUR FEET AND HANDS WARM IN EXTREMELY COLD WEATHER, AND KEEP THEM COOL IN VERY HOT TEMPERATURES. WEAR CLOTHING THAT PROMOTES BLOOD CIRCULATION AT ALL TIMES. CYANOSIS: IS THE CHANGE OF BODY TISSUE COLOR TO A BLUISH-PURPLE HUE, AS A RESULT OF DECREASE IN THE AMOUNT OF OXYGEN BOUND TO THE HEMOGLOBIN TYPES OF CYANOSIS 1- CENTRAL CYANOSIS (ARTERIAL BLOOD OXYGEN SATURATION < 85) (LIPS, EAR LOBES, TIP OF NOSE) CAUSES: 1-CNS INTRACRANIAL HEMORRHAGE, DRUG OVERDOSE (E.G., HEROIN) 2-RESPIRATORY SYSTEM: (PNEUMONIA, BRONCHIOLITIS, BRONCHOSPASM (E.G., ASTHMA), 3-CARDIOVASCULAR SYSTEM: (CONGENITAL HEART DISEASE (E.G., TETRALOGY OF FALLOT, RIGHT TO LEFT SHUNTS IN HEART OR GREAT VESSELS), HEART FAILURE, VALVULAR HEART DISEASE 4-HEMOGLOBINOPATHIES 5-OTHERS: HIGH ALTITUDE, ALTITUDES >2400 M. HYPOTHERMIA, FROSTBITE, OBSTRUCTIVE SLEEP APNEA 2-PERIPHERAL CYANOSIS IS THE BLUE TINT IN FINGERS OR EXTREMITIES, DUE TO AN INADEQUATE OR OBSTRUCTED CIRCULATION TREATMENT OF CYANOSIS: MANAGEMENT SHOULD ALWAYS BEGIN WITH SECURING THE AIRWAY, BREATHING, AND CIRCULATION. SUPPLEMENTAL OXYGEN (IN THE FORM OF NASAL CANULA CONTINUOUS POSITIVE AIRWAY PRESSURE  B-LOCAL INSPECTION 1- HEAD & NECK: (NASAL FLARING- PURSED LIP BREATHING- MOUTH VERSUS NOSE BREATHING- TRACHEAL POSITION-EVIDENCE OF TRAUMA, BRUISING, DEFORMITY, SWELLING FACIAL EXPRESSIONS INDICATING DISTRESS OR FATIGUE CENTRAL CYANOSIS (LIPS, TONGUE) INDICATING HYPOXEMIA USE OF ACCESSORY MUSCLES OF RESPIRATION, MUSCULAR HYPERTROPHY, TRACHEAL POSITION  2- LYMPH NODES LYMPHADENOPATHY OR LYMPHADENITIS (TERMS OFTEN USED SYNONYMOUSLY FOR ABNORMAL SIZE, CONSISTENCY, OR INFLAMMATION OF THE LYMPH NODES) MAY INDICATE INFECTION. INFLAMMATION OF THE SUBMANDIBULAR AND SUBMENTAL LYMPH NODES MAY INDICATE INFECTIONS OF THE ORAL CAVITY TONSILLAR INFLAMMATION MAY INDICATE INFECTIONS OF THE TONSILLAR AND POSTERIOR PHARYNGEAL REGIONS RAISED SUPRACLAVICULAR NODES MAY INDICATE PULMONARY INFECTIONS  3-THORAX INSPECT THE CHEST FOR ABNORMAL CONTOUR, SYMMETRY, PULSATIONS, LIFTS, HEAVES, AND THRUSTS. HEAVE OR LIFT—A VIGOROUS PALPABLE APICAL IMPULSE OBSERVED AT THE (PMI) ON 5TH LICS , MEDIAL TO THE MIDCLAVICULAR LINE. ANTEROPOSTERIOR DIAMETER IS HALF OF TRANSVERSE DIAMETER CHEST DEFORMITIES KYPHOSIS, SCOLIOSIS, PECTUS CARINATUM OR PECTUS EXCAVATUM. OBSERVE THE BREATHING RATE, RHYTHM, DEPTH, AND EFFORT.  4-HANDS & FEET CONSIDER THE HANDS FOR SIGNS OF PERIPHERAL CYANOSIS, PALMAR ERYTHEMA, BRUISING, AND DILATED VEINS. CLUBBING FINGERS :IS FOCAL ENLARGEMENT OF THE CONNECTIVE TISSUE IN THE TERMINAL PHALANGES OF THE DIGITS (LUNG TUMORS AND BRONCHIECTASIS)  THE CAPILLARY REFILL TEST (CRT) IS A RAPID TEST USED FOR ASSESSING THE BLOOD FLOW THROUGH PERIPHERAL TISSUES. IT'S A QUICK TEST PERFORMED ON THE NAIL BEDS TO MONITOR THE AMOUNT OF BLOOD FLOW TO TISSUES AND DEHYDRATION. THE CRT MEASURES THE EFFICACITY OF THE VASCULAR SYSTEM OF HANDS AND FEET AS THEY ARE FAR FROM THE HEART NORMAL RESULTS < 2 SEC ABNORMAL RESULTS>2 SEC FACTORS AFFECTING THE CRT INCLUDE PERIPHERAL VASCULAR DISEASE OLD AGE HYPOTHERMIA COLD AMBIENT TEMPERATURE POOR LIGHTING PRESSURE APPLICATION  EDEMA EDEMA IS ACCUMULATION OF FLUIDS IN INTERSTITIAL SPACES. EDEMA CAN OCCUR IN ANY PART OF THE BODY BUT IS MOST COMMON IN THE HANDS, ARMS, FEET, ANKLES, AND LEGS. Assessing pitting edema is as simple as using a finger to press down on the swollen area and examining the depth of the indentation. CONTINUE EDEMA ASSESSMENT: 1- WATER DISPLACEMENT 2- GIRTH MEASUREMENT  2- PALPATION PALPATE THE THORAX TO ASSESS FOR CHEST WALL TENDERNESS OR MASSES 1-TRACHEAL DEVIATION TRACHEAL POSITION IS EVALUATED TO DETERMINE THE PRESENCE OF MEDIASTINAL SHIFT, WHICH OCCURS WHEN THERE ARE DIFFERENCES IN INTRATHORACIC PRESSURE OR LUNG VOLUMES BETWEEN THE TWO SIDES OF THE THORAX THE DIRECTION OF TRACHEAL DEVIATION DEPENDS ON THE UNDERLYING PATHOLOGY. DEVIATION OCCURS TOWARD THE SIDE OF THE ABNORMALITY (ATELECTASIS, FIBROSIS, OR SURGICAL EXCISION OF LUNG TISSUE). DEVIATION IS AWAY FROM THE SIDE OF THE ABNORMALITY IN TENSION PNEUMOTHORAX AND PLEURAL EFFUSION THE MEDIASTINUM MAY BE SHIFTED TO THE RIGHT IN OLDER PATIENTS WHEN NO LUNG PATHOLOGY EXISTS AS A RESULT OF ELONGATION OF AN ATHEROSCLEROTIC AORTIC ARCH  2-RESPIRATORY MUSCLE ACTIVITY TO ASSESS DIAPHRAGMATIC FUNCTION AND THE PRESENCE OF ACCESSORY MUSCLE RECRUITMENT. DIAPHRAGM WITH THE PATIENT LYING SUPINE AND FLAT, THE EXAMINER PLACES BOTH HANDS LIGHTLY OVER THE ANTERIOR CHEST WITH THUMBS OVER COSTAL MARGINS SO THAT THEIR TIPS ALMOST MEET AT THE XIPHOID. THE PATIENT IS INSTRUCTED TO TAKE A DEEP INSPIRATION WHILE THE EXAMINER’S HANDS ARE ALLOWED TO MOVE WITH CHEST EXPANSION. NORMAL DIAPHRAGMATIC FUNCTION RESULTS IN EQUAL UPWARD MOTION OF EACH COSTAL MARGIN, WHICH PRODUCES AN INCREASE IN THE THORACIC CIRCUMFERENCE OF 2 TO 3 IN. INWARD MOTION OF THE COSTAL MARGINS DURING INSPIRATION OCCURS WHEN THE DIAPHRAGM IS NO LONGER DOME-SHAPED, AS IN COPD  SCALENE MUSCLES WITH THE PATIENT SITTING AND FACING AWAY, THE EXAMINER PLACES HIS OR HER HANDS ON THE UPPER TRAPEZIUS MUSCLES SO THAT THE FINGERS REST ON THE CLAVICLES AND THE THUMBS MEET NEAR THE MIDLINE POSTERIORLY. ACTIVITY OF THE SCALENE MUSCLES IS ASSESSED AS THE PATIENT TAKES AT LEAST TWO QUIET BREATHS. NORMALLY, THE SCALENE MUSCLES ARE ONLY MINIMALLY ACTIVE DURING QUIET BREATHING,  3-TACTILE FREMITUS TACTILE VOCAL FREMITUS IT IS A PALPABLE VIBRATIONS RESULTING FROM THE TRANSMISSION OF VOICE SOUNDS TO THE CHEST WALL THE PATIENT IS THEN INSTRUCTED TO SAY “99,” WHILE THERAPIST APPLY HIS BOTH HANDS ON PATIENT CHEST WALL THE INTENSITY OF THE VIBRATIONS DETECTED IN EACH HAND ARE COMPARED THE EXAMINER MOVES HIS OR HER HANDS OVER SEVERAL AREAS OF THE CHEST (APICAL, ANTERIOR, LATERAL, AND POSTERIOR). UNDER NORMAL CONDITIONS, EQUAL VIBRATIONS OF MODERATE INTENSITY ARE PERCEIVED DURING SPEECH. INCREASED FREMITUS IS NOTED WHEN THERE IS INCREASED DENSITY OF THE UNDERLYING LUNG TISSUE (E.G., CONSOLIDATION) CAUSED BY EXUDATE OR MASS. FREMITUS IS DECREASED OR ABSENT WHEN THERE IS FLUID OR AIR IN THE PLEURAL SPACE OR WHEN THERE IS ATELECTASIS VIBRATIONS ARE DETECTED DURING QUIET BREATHING, IT IS TERMED RHONCHAL FREMITUS DUE TO PARTIAL AIRWAY OBSTRUCTION  4-CHEST EXPANSION THE MOVEMENT OF THORACIC RIB CAGE IS ATTRIBUTED TO THE LUNG EXPANSION AND THE MOVEMENT OF THE RIB CAGE NORMAL CHEST WALL MOBILITY IS IMPORTANT FOR EFFECTIVE LUNG EXPANSION AND SUBSEQUENT VENTILATION PATHOLOGIC CHANGES IN THE LUNGS OR THORACIC CAGE CAN RESTRICT THE THORACIC MOVEMENT. TECHNIQUE: BY BRINGING THUMBS TOGETHER AT THE PATIENT'S MIDLINE AND ASKING THE PATIENT TO BREATHE IN. NORMAL RANGE 5-5.6 CM  5-CHEST EXCURSION CIRCUMFERENTIAL MEASUREMENT AT DIFFERENT LEVELS FROM FULL FORCED EXPIRATION TO ABSOLUTE MAXIMUM INSPIRATION. NORMAL CIRCUMFERENTIAL MEASUREMENT IS 8.48 CM OR 3.25 INCH MEASUERED AT THE ANGLE OF LOUIS ON THE STERNUM, LOCATED AT THE SECOND RIB, FOR UPPER CHEST MOTION THE XIPHOID PROCESS FOR MID-CHEST EXPANSION THE MIDPOINT BETWEEN THE XIPHOID PROCESS AND THE UMBILICUS FOR LOWER CHEST EXPANSION, CAN BE AFFECTED BY A NUMBER OF CONDITIONS: 1-UNILATERAL RESTRICTION DUE TO LOB PNEUMONIA, ATELECTASIS, OR FIBROSIS OR WITH TRAUMA OR A SURGICAL INCISION. 2-BILATERAL RESTRICTION DUE TO PULMONARY FIBROSIS, COPD AND HYPERINFLATED LUNGS. DURING PALPATION OF CWE, THE EXTENT OF MOVEMENT, TIMING, AND SYMMETRY ARE ASSESSED. PALPATION OF CWE IS PERFORMED SEGMENTALLY, COMPARING ONE SIDE WITH THE OTHER DURING QUIET AND DEEP BREATHING, MEASURED WITH A TAPE MEASURE  6-CARDIAC IMPULSE IT’S THE MOST LATERAL POINT WHERE A DEFINITE LOCALIZED SYSTOLIC PULSATION IS FELT IDENTIFIES THE APEX OF THE HEART, IT’S ALSO CALLED THE POINT OF MAXIMAL IMPULSE (PMI). THE APICAL IMPULSE IS NORMALLY LOCATED IN THE FIFTH LEFT INTERCOSTAL SPACE NEAR THE MIDCLAVICULAR LINE AND CONSISTS OF A BRIEF, LOCALIZED, MODERATE INTENSITY EXAGGERATED IN THIN, YOUNG INDIVIDUALS AND WHEN THE INDIVIDUAL IS LYING ON THE LEFT SIDE LATERAL DISPLACEMENT OF THE APICAL IMPULSE INDICATES LV HYPERTROPHY OR MEDIASTINAL SHIFT DUE TO LUNG DISEASE  3-PERCUSSION TO DETERMINE IF THE AREA UNDER THE PERCUSSED FINGER IS AIR FILLED (SOUNDING RESONANT LIKE A DRUM), FLUID FILLED (A DULL SOUND) SOLID (A FLAT SOUND). FINDINGS: 1-WELL-AERATED LUNG TISSUE PRODUCES A LOW-PITCHED, RESONANT SOUND 2-DENSER SUCH AS THE HEART, LIVER, ABDOMINAL VISCERA YIELD A DULLER SOUND 3-LESS DENSE ORGANS AS THE STOMACH PRODUCE A MORE TYMPANIC SOUND 4- SOLID LIKE BONES HEARD AS FLAT SOUND.  APPLICATION OF PERCUSSION PERCUSS THE POSTERIOR, LATERAL, AND ANTERIOR CHEST WALL THE LONG AXIS OF THE PERCUSSED FINGER IS ROUGHLY PARALLEL TO THE RIBS COMPARE ONE SIDE TO THE OTHER TYPES: 1- INDIRECT OVER PERCUSSED HAND 2- DIRECT ON CHEST WALL  DIAPHRAGMATIC EXCURSION THE DISTANCE BETWEEN MAXIMAL EXPIRATION AND MAXIMAL INSPIRATION, WHICH IS NORMALLY 3 TO 5 CM APPLICATION: WITH THE PATIENT SITTING, THE EXAMINER PERFORMS PERCUSSION DOWN THE CHEST UNTIL DULLNESS IS ENCOUNTERED. THE PATIENT IS THEN ASKED TO EXHALE COMPLETELY WHILE THE EXAMINER DEFINES THE LIMIT OF DIAPHRAGMATIC ASCENT. AFTER THE PATIENT TAKES A DEEP BREATH AND HOLDS IT, THE EXAMINER TRACKS DIAPHRAGMATIC MOTION AND IDENTIFIES THE EXTENT OF DESCENT. DIAPHRAGMATIC EXCURSION IS REDUCED BILATERALLY IN COPD. OR UNILATERALLY IF THERE IS UNILATERAL DIAPHRAGMATIC PARALYSIS  4- AUSCULTATION AUSCULTATION ENTAILS LISTENING TO THE PATIENT’S CHEST WITH A STETHOSCOPE TO IDENTIFY LUNG OR HEART SOUND AUSCULTATION OF THE CHEST PROVIDES IMPORTANT INFORMATION ABOUT THE CONDITION OF THE LUNGS, HEART AND PLEURA THE OPTIMAL POSITION OF THE PATIENT IS SITTING IN A CHAIR OR ON THE SIDE OF A BED  THE PROPER TECHNIQUE CONSISTS OF THE FOLLOWING STEPS IDEALLY, THE PATIENT SHOULD BE IN A QUIET ROOM IN A SITTING POSITION WITH BARE SKIN EXPOSED AND SHOULD BREATHE DEEPLY BUT SLOWLY THROUGH AN OPEN MOUTH. USING THE DIAPHRAGM OF THE STETHOSCOPE, SYSTEMATICALLY LISTEN TO THE ENTIRE LUNG SPACE (ANTERIOR AND THEN POSTERIOR AND LATERAL, OR VICE VERSA) WITH AT LEAST ONE BREATH PER BRONCHOPULMONARY SEGMENT, ALTERNATING BETWEEN SIMILAR LOCATIONS ON THE RIGHT AND LEFT SIDES AND COMPARING INTENSITY, PITCH, AND QUALITY, WHILE MOVING FROM THE UPPER TO LOWER CHEST. SPECIFIC PRECAUTION SHOULD BE TAKEN: PATIENTS WHO ARE WEAK OR HAVE POOR BALANCE OR ORTHOSTATIC INTOLERANCE SHOULD BE OFFERED ADDITIONAL SUPPORT IN THE SITTING POSITION TO PREVENT FALLING. THE THERAPIST SHOULD MOVE SLOWLY FROM ONE PULMONARY SEGMENT TO THE NEXT IN ORDER TO AVOID PATIENT DIZZINESS AS A RESULT OF HYPERVENTILATION FROM DEEP BREATHS BEING PERFORMED TOO RAPIDLY. APPROPRIATE DRAPING SHOULD BE MAINTAINED DURING AUSCULTATION SO FEMALES ARE NOT EMBARRASSED BY HAVING THE CHEST- BARED MAIN AREAS OF AUSCULTATION ANTERIOR CHEST: APEX OF THE LUNG: AT THE SUPRACLAVICULAR FOSSA. SUPERIOR LOBE: AT THE SECOND INTERCOSTAL SPACE, MIDCLAVICULAR LINE. MIDDLE LOBE (RIGHT SIDE) + LINGULA (LEFT SIDE) : AT THE 5TH RIB, MIDCLAVICULAR LINE. INFERIOR LOBE: AT THE SEVENTH INTERCOSTAL SPACE, MIDAXILLARY LINE MAIN AREAS OF AUSCULTATION APEX OF THE LUNG: SUPERIOR TO THE MEDIAL ANGLE OF THE SCAPULAR SPINE. SUPERIOR LOBE: MEDIAL TO THE SCAPULAR SPINE. INFERIOR LOBE: 5CM INFEROMEDIALLY TO THE INFERIOR ANGLE OF THE SCAPULA. LUNG BASE: AT THE LEVEL OF T10, 5CM LATERAL TO THE VERTEBRAL COLUMN  NORMAL BREATHING SOUNDS 1-VESICULAR: QUIET LOW PITCHED , INSPIRATORY > EXPIRATORY PHASE HEARD IN MOST LUNG FIELDS 2-BRONCHOVESICULAR; MEDIUM IN PITCH , INSPIRATORY = EXPIRATORY PHASE, HEARD PARASTERNAL & INTERSCAPULAR 3-BRONCHIAL: HIGHER PITCHED, EXPIRATORY >INSPIRATORY PHASE HEARD AROUND 2ND AND 3RD INTERCOSTAL SPACE ANTERIORLY 4-TRACHEAL: LOUD HIGH PITCHED , INSPIRATORY=EXPIRATORY PHASE HEARD OVER TRACHEA IN NORMAL CHEST 4 TYPES OF SOUNDS ARE USUALLY HEARD  ABNORMAL BREATH SOUNDS 1-CRACKLES: DISCONTINUOUS NON MUSICAL SOUNDS HIGH-PITCHED POPPING SOUNDS MOST COMMON DURING INSPIRATION COME FROM FLUID IN AIRWAYS OR FROM OPENING OF COLLAPSED ALVEOLI. 2-WHEEZES: CONTINUOUS MUSICAL SOUNDS, HIGH PITCH AND PERSIST THROUGH RESPIRATORY CYCLE CAUSED BY AIR MOVEMENT THROUGH NARROWED OR PARTIALLY OBSTRUCTED AIRWAY, E. G. ASTHMA COPD. BRONCHITIS 3-RHONCHI: CONTINUOUS BREATH SOUND LOW-PITCHED RUMBLING NOISES INDICATES PRESENCE OF SECRETIONS IN LARGE AIRWAYS CONDITIONS INCLUDE BRONCHITIS THESE SOUNDS MAY CLEAR WITH COUGHING 4-STRIDOR: MUSICAL ,LOUD , HIGH PITCH CAUSED BY OBSTRUCTION OF UPPER AIRWAY 4-PLEURAL RUB: CRACKLING GRATING SOUND HEARD DURING RESPIRATORY CYCLE MORE OFTEN WITH INSPIRATION THAN EXPIRATION CAN BE PRESENT WITH PLEURAL EFFUSION, PLEURISY, PNEUMOTHORAX