1. 1 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 5 Fundamentals of Physical Examination

2. 2 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives After reading this chapter you will be able to:  Describe the four components of the physical examination  Explain the importance of reviewing the history of present illness before performing a physical examination

3. 3 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives (cont’d)  Describe the significance of the following during examination of the head and neck:  Nasal flaring  Pursed-lip breathing  Diaphoresis  Changes in pupillary size in response to light  Cyanosis  Deviated tracheal position  Jugular venous distention

4. 4 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives (cont’d)  Identify the correct method for measuring jugular venous pressure and expected normal findings

5. 5 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives (cont’d)  Locate the position of the following:  Thoracic cage landmarks (suprasternal notch, sternal angle [angle of Louis], vertebral spinous processes [C7 and T1])  Lung fissures (oblique [major] and horizontal [minor])  Tracheal bifurcation anteriorly and posteriorly  Right and left diaphragm anteriorly and posteriorly  Lung borders

6. 6 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives (cont’d)  Define the following terms that classify thoracic configuration during inspection of the chest:  Pectus carinatum; pectus excavatum; kyphosis; scoliosis; kyphoscoliosis; barrel chest; flail chest

7. 7 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives (cont’d)  Define the following terms used to describe breathing pattern during inspection of the chest:  Apnea; Biot’s breathing; Cheyne-Stokes breathing; Kussmaul’s breathing; apneustic; paradoxical breathing; asthmatic

8. 8 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives (cont’d)  Describe the breathing patterns associated with restrictive and obstructive lung disease  Describe the clinical significance of accessory muscle usage and retractions and bulging

9. 9 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives (cont’d)  Identify the following terms and their significance:  Abdominal paradox  Respiratory alternans  Peripheral cyanosis  Central cyanosis  Hoover’s sign

10. 10 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives (cont’d)  Describe the clinical significance of peripheral versus central cyanosis  List causes of increased and decreased tactile fremitus  List causes of decreased thoracic expansion as assessed during chest palpation

11. 11 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives (cont’d)  Describe subcutaneous emphysema and its clinical significance  List causes of increased and decreased resonance during percussion of the lung  Identify the four basic parts of a stethoscope and their uses

12. 12 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives (cont’d)  Describe the proper technique for auscultation of the lungs  Identify the four characteristics of breath sounds that should be evaluated during auscultation

13. 13 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives (cont’d)  Define the following terms used to describe lung sounds and the mechanisms responsible for producing the sounds:  Tracheal  Bronchovesicular  Vesicular (normal)  Diminished/absent  Harsh/bronchial

14. 14 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives (cont’d)  Define the following terms that describe abnormal (adventitious) lung sounds and the mechanisms responsible for producing the sounds:  Crackles (rales); wheezes; stridor; pleural friction rub  Use qualifying adjectives to describe lung sounds and explain the importance of using these qualifying adjectives

15. 15 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives (cont’d)  Describe the significance of the following auscultatory findings:  Monophonic wheeze; polyphonic wheezes; stridor; late inspiratory crackles; inspiratory and expiratory crackles; pleural friction rub

16. 16 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives (cont’d)  Define bronchophony and its cause  Identify the topographic location of the apex and base of the heart during examination of the precordium  Identify the point of maximal impulse, its normal location, and the factors that may cause it to shift to the right or left

17. 17 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives (cont’d)  Describe the best location for auscultating sounds produced by the aortic, pulmonic, mitral, and tricuspid valves  Describe what produces the first (S 1 ), second (S 2 ), third (S 3 ), and fourth (S 4 ) heart sounds  Describe what is meant by a “gallop rhythm” and what it signifies

18. 18 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives (cont’d)  List the factors that increase or decrease the intensity of the heart sounds  Describe the clinical significance of a loud P 2 heard during auscultation of the heart  Describe the factors that cause systolic and diastolic heart murmurs

19. 19 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives (cont’d)  Define the term “hepatomegaly” and its significance in the cardiopulmonary patient  Define the following terms and their significance during examination of the extremities:  Digital clubbing; cyanosis; pedal edema; capillary refill; peripheral skin temperature

20. 20 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Introduction  The four basic components of physical examination are: 1. Inspection 2. Palpation 3. Percussion 4. Auscultation

21. 21 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Introduction (cont’d)  The initial examination is most often performed by the attending physician to assist in making the diagnosis  Subsequent examinations are performed by other members of the health care team to monitor the patient’s progress and assess the patient’s response to treatment

22. 22 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Examination of the Head and Neck  Examine facial expression; may provide clues to the mental status of the patient  Nasal flaring is a sign of labored breathing  Cyanosis of the lips and tongue indicates inadequate oxygenation of the blood  Diaphoresis: a sign of stress and common in patients having a myocardial infarction

23. 23 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Examination of the Eyes  Pupillary reflexes tested by shinning a light into the patient’s eyes  Pupils should be equal, round, reactive to light, and accommodation (PERRLA)  Dilated pupils that respond poorly to light often a sign of neurologic damage  Ptosis (drooping eyelid) sign of neuromuscular disease (myasthenia gravis)

24. 24 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Examination of the Neck  Assess for jugular venous distention  JVD is a sign of right heart failure (Figures 5-1 and 5-2)  Assess for tracheal position; the trachea may shift left or right of center when one lung collapses or when a tumor is present in the neck or upper mediastinum  Palpate for lymphadenopathy; could occur with infection or malignancy

25. 25 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Lung Topography  Imaginary lines (Figures 5-3 to 5-5)  Thoracic cage landmarks (Figures 5-6 and 5-7)  Lung fissures (Figures 5-8 and 5-9)  Tracheal bifurcation  Diaphragm  Lung borders (Figure 5-9)

26. 26 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Chest Examination  Inspection  An abnormal increase in A-P diameter is known as a barrel chest (COPD) (Figure 5-10)  Kyphosis is an abnormal A-P curvature of the spine  Scoliosis is an abnormal lateral curvature of the spine (Figure 5-11)

27. 27 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Breathing Pattern

28. 28 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Breathing Pattern and Effort  Rapid and shallow breathing is consistent with restrictive lung disease  A prolonged expiratory time is consistent with intrathoracic airway obstruction  A prolonged inspiratory time is consistent with upper airway obstruction  Use of the accessory muscles indicates an increase in the work of breathing

29. 29 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Breathing Pattern and Effort (cont’d)  Abdominal paradox occurs when the diaphragm fatigues and the abdomen sinks inward with each inspiratory effort  Respiratory alternans also occurs with diaphragm fatigue and is seen as alternating between breathing only with the chest muscles and only breathing with the diaphragm

30. 30 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Chest Palpation  Vocal fremitus: ask the patient to repeat the words “ninety nine” while you palpate over the chest in a systematic manner  Increased with pneumonia and atelectasis  Decreased with emphysema and pneumothorax

31. 31 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Chest Palpation (cont’d)  Thoracic expansion  Normally both sides of the chest expand evenly with normal or deep breathing  One side may underexpand when atelectasis, pneumonia, or a lung tumor is present  Both sides may expand poorly with emphysema

32. 32 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Chest Percussion  Done during examination to assess resonance of the underlying tissue  Normal air-filled lung moderately resonant  Hyperinflated lung (emphysema) and pneumothorax will demonstrate increased resonance to percussion  Decreased resonance with pneumonia, atelectasis, and pleural effusion

33. 33 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Chest Auscultation  Chest auscultation performed with a stethoscope  Bell  Diaphragm  Tubing  Ear pieces  The diaphragm is most often used to auscultate lung sounds

34. 34 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Chest Auscultation (cont’d)

35. 35 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Auscultation Technique  Ask patient to breathe a little deeper than normal  Start at the bases and work toward the apices  Compare sounds from one side to the other  Listen for breath sounds and adventitious lung sounds

36. 36 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Terminology for Breath Sounds  Tracheal breath sounds: loud, high-pitched breath sound heard directly over the trachea with an equal inspiratory and expiratory component  Normal (vesicular) breath sounds: soft, low-pitched sound heard over normal lung parenchyma; have a minimal expiratory component

37. 37 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Abnormal Breath Sounds  Harsh breath sounds: a louder version of the normal breath sound  Bronchial breath sound: a louder version of the normal breath sound with an equal inspiratory and expiratory component  Diminished breath sound: softer version of the normal breath sound  Absent breath sound: no sound heard

38. 38 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Terminology for Adventitious Lung Sounds  Crackles: discontinuous ALS heard most often on inspiration  Wheezes: continuous ALS heard most often on exhalation  Stridor: monophonic, high-pitched wheeze heard over the upper airway in patients with croup or epiglottitis

39. 39 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Mechanisms for Breath Sounds  Normal breath sounds are created primarily by turbulent flow in the larger airways with breathing  Diminished breath sounds occur with shallow breathing or increased attenuation  Harsh or bronchial breath sounds occur with decreased attenuation

40. 40 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Interpretation of Breath Sounds  Normal breath sounds indicate good air exchange in the underlying lung  Diminished breath sounds suggest shallow breathing or hyperinflation of the lung as with emphysema  Bronchial breath sounds suggest an increase in lung density as occurs with pneumonia

41. 41 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Mechanisms for ALS  Crackles: produced by the sudden opening of collapsed airways or with the movement of excessive airways secretions  Wheezes: produced by vibration of the narrowed airway walls as air flows through at high speeds  Stridor: produced by vibration of tissues in the upper airway with labored breathing

42. 42 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Mechanisms for ALS (cont’d)

43. 43 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Examination of the Precordium

44. 44 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Examination of the Precordium (cont’d)  Precordium is inspected and palpated for normal and abnormal pulsations  The normal point of maximal impulse is created by a healthy left ventricular systole  It is usually felt in the 5th intercostal space on the left at the midclavicular line  Abnormal pulsation on precordium can occur with right/left ventricular hypertrophy

45. 45 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Auscultation of Heart Sounds  First heart sound (S 1 ): produced by closure of the AV valves with systole  Second heart sound (S 2 ): produced by closure of semilunar valves during diastole  When valves do not close simultaneously a split heart sound is heard; slight splitting may be normal; significant splitting implies defect in the electrical conduction system

46. 46 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Auscultation of Heart Sounds (cont’d)  S 3 or S 4 heart sound may be heard in patients with ventricular hypertrophy  This is called a gallop rhythm and usually indicates overdistention of one of the ventricles  A loud P 2 is suggestive of pulmonary hypertension and is common in COPD patients with chronic hypoxemia

47. 47 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Cardiac Murmurs  Caused by rapid blood flow through a narrowed valve or backflow through an incompetent valve  Systolic murmurs occur when blood passes through narrowed semilunar valves or back flows through incompetent AV valves  Diastolic murmurs occur with stenotic AV valves or incompetent semilunar valves

48. 48 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Examination of the Abdomen  Performed to inspect and palpate for distention or tenderness  An enlarged or tender abdomen can negatively influence breathing  A large liver is known as hepatomegaly; common in patients with cor pulmonale  An abnormal collection of fluid in the peritoneal cavity is known as ascites

49. 49 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Examination of the Extremities  Digital clubbing can be a serious sign of chronic cardiopulmonary disease  Peripheral cyanosis is consistent with poor circulation  Pedal edema may be sign of heart failure; chronic right heart failure is common in COPD patients with cor pulmonale  Cool extremities indicate poor circulation

50. 50 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Summary  Physical examination provides reliable and important evidence regarding the patient’s clinical condition  RTs must be skilled at PE to assess the patient’s condition and evaluate the effects of treatments  The best evaluation usually comes from looking at multiple parameters from the PE