fundamentals of the chest physical exam resd 60 bedside assessment skills patient interview ...

Fundamentals of the Fundamentals of the Chest Physical ExamChest Physical Exam

RESD 60RESD 60

Bedside Assessment SkillsBedside Assessment Skills

Patient InterviewPatient Interview

History TakingHistory Taking

Physical ExaminationPhysical Examination

Medical Record Medical Record KeepingKeeping

Respiratory RecapRespiratory Recap

Variables supporting a therapeutic climateVariables supporting a therapeutic climate Caring DemeanorCaring Demeanor CompetenceCompetence Eye ContactEye Contact Judicious use of touchJudicious use of touch Professional ImageProfessional Image

Terms used to describe illnessTerms used to describe illness

SymptomSymptom SignSign FindingFinding SyndromeSyndrome DiseaseDisease

SymptomSymptom Something felt by an individual as a Something felt by an individual as a

departure from normal. departure from normal.

A subjective abnormality perceived by the A subjective abnormality perceived by the patient.patient.

Examples:Examples: dyspneadyspnea chest painchest pain leg swellingleg swelling

SignSign

An observable or measurable bodily An observable or measurable bodily manifestation that serves to indicate the manifestation that serves to indicate the presence of malfunction or disease.presence of malfunction or disease.

Examples:Examples: tachypneatachypnea dullness to percussiondullness to percussion pedal edemapedal edema

Sign or symptomSign or symptom

In the investigation of a symptom or sign In the investigation of a symptom or sign be quantitative whenever possible.be quantitative whenever possible.

““8 on a scale of 10”8 on a scale of 10”

““2 to 3 minutes”2 to 3 minutes”

FindingFinding

An observation or manifestation of disease as a An observation or manifestation of disease as a result of an investigative procedure.result of an investigative procedure.

Typical procedures; blood work, radiology.Typical procedures; blood work, radiology.

Examples:Examples: right lower lobe infiltrateright lower lobe infiltrate increase white blood cell count.increase white blood cell count.

SyndromeSyndrome

A set of symptoms, signs, and/or findings A set of symptoms, signs, and/or findings that characteristically occur together which that characteristically occur together which may signify a specific disease process.may signify a specific disease process.

ExamplesExamples COPDCOPD pneumoniapneumonia

DiseaseDisease

A particular pathologic condition or A particular pathologic condition or process whose pathophysiology or cause process whose pathophysiology or cause is known.is known.

ExamplesExamples pneumococcal pneumoniapneumococcal pneumonia alpha-1-antitrypsin deficiencyalpha-1-antitrypsin deficiency

Cardinal signs and symptoms of Cardiopulmonary Cardinal signs and symptoms of Cardiopulmonary DiseaseDisease

DyspneaDyspnea

CoughCough

HemoptysisHemoptysis

Chest PainChest Pain

Cardinal signs and symptoms of Cardinal signs and symptoms of Cardiopulmonary DiseaseCardiopulmonary Disease

WheezingWheezing

StridorStridor

CyanosisCyanosis

ClubbingClubbing

EdemaEdema

DyspneaDyspnea

Shortness of breathShortness of breath

The subjective sensation that one’s The subjective sensation that one’s breathing is inadequate or insufficient.breathing is inadequate or insufficient.

An uncomfortable awareness of the act of An uncomfortable awareness of the act of breathing.breathing.

CoughCough

A sudden, noisy expulsion of air from the lungs, A sudden, noisy expulsion of air from the lungs, brought about through a reflex action, for the brought about through a reflex action, for the purpose of clearing the airways.purpose of clearing the airways.

A normal event that becomes a symptom when it A normal event that becomes a symptom when it is frequent or bothersome.is frequent or bothersome.

Nonproductive or productiveNonproductive or productive

HemoptysisHemoptysis

The coughing up of blood from the The coughing up of blood from the respiratory tract below the level of the respiratory tract below the level of the larynx.larynx.

This term is usually reserved for fresh This term is usually reserved for fresh blood.blood.

Chest PainChest Pain

Any uncomfortable sensation referable by Any uncomfortable sensation referable by the patient to the thoracic area.the patient to the thoracic area.

Pleuritic - worsened by breathing or Pleuritic - worsened by breathing or coughing.coughing.

WheezingWheezing

A high-pitched, musical sound produced A high-pitched, musical sound produced when the patient breathes, originating in when the patient breathes, originating in narrowed airways.narrowed airways.

May occupy either a portion or all of the May occupy either a portion or all of the respiratory cycle.respiratory cycle.

StridorStridor

A harsh, high-pitched sound, usually on A harsh, high-pitched sound, usually on inspiration.inspiration.

Associated with partial laryngeal Associated with partial laryngeal obstruction.obstruction.

CyanosisCyanosis

A A bluishbluish discoloration of the skin and discoloration of the skin and mucous membranes due to the presence mucous membranes due to the presence of increased quantities of reduced of increased quantities of reduced hemoglobin.hemoglobin.

Cyanosis may be peripheral or central.Cyanosis may be peripheral or central.

CyanosisCyanosis

ClubbingClubbing

Enlargement of the Enlargement of the end of the fingers and end of the fingers and toes due to buildup of toes due to buildup of soft tissue in the nail soft tissue in the nail bed.bed.

Occurs in several Occurs in several chronic lung chronic lung diseases.diseases.

Clubbing of the fingersClubbing of the fingers

EdemaEdema

Presence of large amts of fluid in the intercellular tissue spaces of the body.

Pitting - seen with CHF. Increased fluid due to increased hydrostatic pressure.

Non-pitting - seen with infection due to increased capillary permeability.

Pitting EdemaPitting Edema

Present IllnessPresent Illness

The present illness is the clinical The present illness is the clinical problem of primary concern at the problem of primary concern at the moment.moment.

The chief complaint is what caused The chief complaint is what caused the patient to seek medical attentionthe patient to seek medical attention..

Physical ExaminationPhysical Examination

A physical examination is done to detect A physical examination is done to detect the the physical signs of disease.the the physical signs of disease.

The RCP has 3 considerations:The RCP has 3 considerations: DiagnosticDiagnostic TherapeuticTherapeutic EvaluationEvaluation

Components of Physical ExaminationComponents of Physical Examination

InspectionInspection

PalpationPalpation

PercussionPercussion

AuscultationAuscultation

InspectionInspection

View from the doorView from the door

IsolationIsolation

patient positionpatient position

FamilyFamily

equipmentequipment

Entering the roomEntering the room

IntroductionIntroduction

Patient’s last namePatient’s last name

Establish a brief Establish a brief rapportrapport

Vital SignsVital Signs

body temperaturebody temperature

heart rateheart rate

respiratory raterespiratory rate

blood pressureblood pressure

SensoriumSensorium

An alert patient is oriented to person, An alert patient is oriented to person, place and time.place and time.

An abnormal sensorium suggests that a An abnormal sensorium suggests that a person may have poor oxygenation.person may have poor oxygenation.

Can also occur with drugs and disease Can also occur with drugs and disease states.states.

Physical Inspection - Head to Physical Inspection - Head to ToeToe

HeadHead facial expressionfacial expression colorcolor nosenose mouthmouth eyeseyes

Physical InspectionPhysical Inspection

NeckNeck

Tracheal positionTracheal position

Jugular venous pressureJugular venous pressure

Accessory muscle useAccessory muscle use

TracheaTrachea

Tracheal Deviation to the RTracheal Deviation to the R

Jugular Venous PressureJugular Venous Pressure

JVDJVD

Chest configurationChest configuration

The normal adult thorax is The normal adult thorax is broader for side to side than front broader for side to side than front to back.to back.

An increased anteroposterior (AP) An increased anteroposterior (AP) diameter is common with diameter is common with emphysema. Barrel chest.emphysema. Barrel chest.

Chest configurationChest configuration

Pectus excavatum - funnel shaped depression of the lower portion of the sternum.

Pectus carinatum - sternum protrudes outward.

Sternal AbnormalitiesSternal Abnormalities

Increased A-P DiameterIncreased A-P Diameter

Physical examination - spinal Physical examination - spinal column.column.

Scoliosis - abnormal, lateral curvature of Scoliosis - abnormal, lateral curvature of the spine.the spine.

Kyphosis - an increased AP curvature of Kyphosis - an increased AP curvature of the spine.the spine.

Kyphoscoliosis - combinationKyphoscoliosis - combination

KyphosisKyphosis

Physical examination - Physical examination - breathing patternbreathing pattern

Respiratory rate and pattern are always Respiratory rate and pattern are always evaluated.evaluated.

Rapid and shallow breathing is associated Rapid and shallow breathing is associated with restrictive lung disease.with restrictive lung disease.

Prolonged expiratory time is common with Prolonged expiratory time is common with obstructive disease.obstructive disease.

Physical Examination - Physical Examination - breathing patternbreathing pattern

Note the timing of the inspiratory and Note the timing of the inspiratory and expiratory phase of breathing.expiratory phase of breathing.

A prolonged expiratory time is common with A prolonged expiratory time is common with obstruction of the intrathoracic airways.obstruction of the intrathoracic airways.

Obstruction of the upper airway leads to Obstruction of the upper airway leads to prolonged inspiratory time.prolonged inspiratory time.

Breathing patternBreathing pattern

Assess the patient’s effort to breathe.Assess the patient’s effort to breathe.

Look for:Look for: retractionsretractions paradoxical respirationsparadoxical respirations flail chestflail chest chest symmetrychest symmetry Pursed lipsPursed lips TripodingTripoding

Pursed LipsPursed Lips

Tripod and Pursed LipsTripod and Pursed Lips

Physical examination - digitsPhysical examination - digits

The digits are inspected for:The digits are inspected for: cyanosiscyanosis clubbingclubbing

PalpationPalpation

Palpation is used to evaluate the symmetry and degree of chest expansion with breathing.

Tactile Fremitus

Capillary Refill

Tracheal position

To palpate, percuss and auscultate To palpate, percuss and auscultate chest you must know the anatomy.chest you must know the anatomy.

Posterior ViewPosterior View

Palpating for Lung ExpansionPalpating for Lung Expansion

PercussionPercussion

Percussion is performed to help evaluate Percussion is performed to help evaluate relative amounts of air and solid material relative amounts of air and solid material in the underlying lung.in the underlying lung.

Percussion over normal air-filled lung will Percussion over normal air-filled lung will produce a drum like sound described as produce a drum like sound described as normal resonance.normal resonance.

PercussionPercussion

Increased or hyper resonance is a , lower pitched sound.

This occurs with emphysema or pneumothorax.

PercussionPercussion

Dull or flat describes a note that is softer and higher-pitched than normal.

This sound is heard over areas of pneumonia, atelectasis, lung tumor, or pleural effusion.

Tactile FremitusTactile Fremitus

AuscultationAuscultation

Auscultation is the process of listening to Auscultation is the process of listening to sounds produced within the body with a sounds produced within the body with a stethoscope.stethoscope.

Whenever possible the patient should be Whenever possible the patient should be sitting upright.sitting upright.

StethoscopeStethoscope

Anterior AuscultationAnterior Auscultation

Lateral AuscultationLateral Auscultation

Posterior AuscultationPosterior Auscultation

AuscultationAuscultation

Inspiration and expiration should be Inspiration and expiration should be evaluated for length and adventitious evaluated for length and adventitious sounds.sounds.

Auscultate directly on the skin when Auscultate directly on the skin when possible.possible.

Auscultate anterior, lateral, and posterior Auscultate anterior, lateral, and posterior chest wall surfaces.chest wall surfaces.

Normal Breath SoundsNormal Breath Sounds

Normal breath sounds are divided into Normal breath sounds are divided into three different typesthree different types

BronchialBronchial

BronchovesicularBronchovesicular

VesicularVesicular

Bronchial breath soundsBronchial breath sounds

Loud and high-pitchedLoud and high-pitched

equal inspiratory and expiratoryequal inspiratory and expiratory

heard over tracheaheard over trachea

also called tracheal, tracheobronchial or also called tracheal, tracheobronchial or tubulartubular

Bronchovesicular breath soundsBronchovesicular breath sounds

Softer and lower pitched than bronchial Softer and lower pitched than bronchial breath sounds.breath sounds.

Heard on the anterior chest near the Heard on the anterior chest near the mainstem bronchi in the first and second mainstem bronchi in the first and second intercostal spaces.intercostal spaces.

Heard on the posterior chest between the Heard on the posterior chest between the scapulae.scapulae.

Vesicular breath soundsVesicular breath sounds

Soft, low-pitched sounds, heard during Soft, low-pitched sounds, heard during auscultation over the lung.auscultation over the lung.

Normal air-filled lung contains millions of Normal air-filled lung contains millions of alveoli, which act as a sound filter to alveoli, which act as a sound filter to turbulent flow in the central airways.turbulent flow in the central airways.

Vesicular breath soundsVesicular breath sounds

Flow in the peripheral airways is laminar Flow in the peripheral airways is laminar and does not contribute significantly to and does not contribute significantly to sound production.sound production.

If the vesicular breath sound is softer than If the vesicular breath sound is softer than expected, it is describes as diminished, expected, it is describes as diminished, decreased, or even absent.decreased, or even absent.

Vesicular breath soundsVesicular breath sounds

Breath sounds are decreased with the Breath sounds are decreased with the following:following: shallow breathingshallow breathing hyperinflationhyperinflation obstructed airwaysobstructed airways pleural effusionpleural effusion pneumothoraxpneumothorax obesityobesity

Vesicular breath soundsVesicular breath sounds

Louder than expected vesicular breath Louder than expected vesicular breath sounds are described as harsh.sounds are described as harsh.

Consolidation does not filter sound, but Consolidation does not filter sound, but allows them to pass through the lung more allows them to pass through the lung more directly.directly.

Adventitious breath soundsAdventitious breath sounds

Abnormal sounds heard during Abnormal sounds heard during auscultation are termed adventitious auscultation are termed adventitious breath sounds.breath sounds.

The can be continuous, musical sounds or The can be continuous, musical sounds or discontinuous, non-musical.discontinuous, non-musical.

Continuous/musicalContinuous/musical

Wheeze - low pitched sound resulting from Wheeze - low pitched sound resulting from narrowing of the airways.narrowing of the airways.

Timing is usually expiratory, but can be Timing is usually expiratory, but can be inspiratory or both.inspiratory or both.

““louder” wheezes usually mean moderate louder” wheezes usually mean moderate obstruction.obstruction.

Continuous/musicalContinuous/musical

Low pitched continuous sounds are Low pitched continuous sounds are termed rhonchi.termed rhonchi.

Timing is usually expiratory.Timing is usually expiratory.

Indicative of secretions in the lung.Indicative of secretions in the lung.

Continuous/musicalContinuous/musical

A high-pitched continuous sound heard A high-pitched continuous sound heard over the upper airway is referred to as over the upper airway is referred to as stridor.stridor.

Stridor is often audible and can be a sign Stridor is often audible and can be a sign of a life-threatening disorder.of a life-threatening disorder.

Discontinuous SoundsDiscontinuous Sounds

Sounds described as intermittent, Sounds described as intermittent, crackling, bubbling, and of short duration.crackling, bubbling, and of short duration.

Termed rales or Termed rales or crackles.crackles.

CracklesCrackles

Produced by two mechanisms;Produced by two mechanisms;

excessive airway secretions with breathing excessive airway secretions with breathing and sudden opening of the small airways.and sudden opening of the small airways.

Sudden opening of the small airways.Sudden opening of the small airways.

CracklesCrackles

Crackles are inspiratory sounds and Crackles are inspiratory sounds and associated with restrictive disorders such associated with restrictive disorders such as:as: atelectasis (late inspiratory)atelectasis (late inspiratory) pneumoniapneumonia pulmonary fibrosispulmonary fibrosis

Voice SoundsVoice Sounds

Normally, air-filled lung filters the voice so Normally, air-filled lung filters the voice so that it is heard as low-pitched mumble that it is heard as low-pitched mumble over the chest wall.over the chest wall.

When lung tissue becomes dense, vocal When lung tissue becomes dense, vocal resonance increases and the voice is resonance increases and the voice is heard more clearly.heard more clearly.

Voice SoundsVoice Sounds

Increase in vocal resonance is termed Increase in vocal resonance is termed bronchophony.bronchophony.

An increase in vocal resonance is heard An increase in vocal resonance is heard with the consolidation that occurs with with the consolidation that occurs with pneumonia.pneumonia.

Voice SoundsVoice Sounds

A decrease in vocal resonance occurs A decrease in vocal resonance occurs when the lung becomes less dense, as when the lung becomes less dense, as with hyperinflation.with hyperinflation.

Voice SoundsVoice Sounds

When to voice sound increases in intensity When to voice sound increases in intensity and takes on a nasal or bleating and takes on a nasal or bleating characteristic, it is termed characteristic, it is termed egophony.egophony.

Ask the patient to say “e” and the “e” will Ask the patient to say “e” and the “e” will be heard as “a” over the area of be heard as “a” over the area of consolidation.consolidation.

Voice SoundsVoice Sounds

When consolidation is present, whispered When consolidation is present, whispered sounds are transmitted more directly.sounds are transmitted more directly.

When whispered sounds are heard with When whispered sounds are heard with more clarity, they are described as more clarity, they are described as whispered pectoriloquy.whispered pectoriloquy.

Neurological AssessmentNeurological Assessment

LOC – Level of ConsciousnessLOC – Level of Consciousness

Glasgow comma scaleGlasgow comma scale

PERRLA—pupils equal, round, and PERRLA—pupils equal, round, and reactive to light and reactive to light and accommodationaccommodation

Neurologic AssessmentNeurologic Assessment

PosturingPosturing

DecerebrateDecerebrate

DecorticateDecorticate