PHYSICAL EXAMINATION Flashcards
Topographic markers on the chest include:
(a) The nipples.
(b) The angle of Louis (manubriosternal junction) that correlates to the second rib (reference point to begin counting ribs).
(c) The suprasternal notch.
(d) The Costal angle (usually no more than 90 degrees, with ribs inserted at 45-degree angles).
(e) The vertebra prominence (The spinous process of C7. It can be more readily seen and felt with the patient’s head bent forward. If two prominences are felt, the upper is that of the spinous process of C7, and the lower is that of T1).
(f) The clavicles (each intercostal space corresponds to that of the rib immediately above it).
Pregnancy
Estrogen increase causes
the ligaments of the rib cage to relax, and chest expansion increases.
1) An increase in the lateral diameter of about 2 cm and an increase in the circumference of 5-7 cm.
2) The subcostal angle progressively increases from about 68.5 degrees to approximately 103.5 degrees later in pregnancy.
3) The diaphragmatic movement increases and the major work of breathing is done by the diaphragm.
Pregnant women have deeper breathing and slightly increased rate of respirations.
Older adults
results from loss of muscle strength in thorax and diaphragm,
coupled with decreased lung resiliency.
The chest wall may stiffen, and expansion is decreased.
1:1 Ratio
Barrel chest
1) Loss of some interalveolar folds and tensile strength occurs, resulting in under ventilation of the ________ and a decreased tolerance for exertion.
2) These changes create a decrease in vital capacity and an increase in residual volume.
3) Dyspnea can occur when older adults exceed exertional demands.
This is due to what?
The alveoli: in older adults are less elastic and more fibrous.
a) The onset and nature of the cough (exercise, could it be asthma?
Persistent cough can sometimes be only symptom.)
b) Sputum characteristics
c) Pattern and severity of the cough
d) Associated symptoms (e.g., hoarseness)
e) Efforts to treat.
patient coughs or complains of coughing.
a) The onset of the problem
b) Pattern and factors facilitating or relieving it
c) Number of pillows the patient sleeps on at night (Orthopnea/platypnea)
d) Associated symptoms (e.g., such as diaphoresis)
e) Efforts to treat.
patient has or complains of shortness of breath.
(1 Constant ache lasting all day.
(2 Does not radiate.
(3 Made worse by pressing on the chest.
(4 Is a fleeting, needle-like jab that last only a few seconds.
(5 It is situated in the shoulders or between the shoulder blades in the back.
Complaints or signs of chest pain should be noted, along with their onset and duration, associated symptoms (e.g., fever), and any treatment efforts.
Other medications: Prescription or nonprescription, street drugs (e.g., cocaine)
Pertinent data include:
1) Past thoracic trauma or surgery
2) Use of oxygen
3) Chronic pulmonary diseases
4) Other systemic disorders (e.g., cancer), related respiratory tests, immunization against pneumonia, influenza, and the use of daily medications, both prescription and non-prescription.
Family History
(a) Tuberculosis
(b) Cystic fibrosis
(c) Empyema
(d) Allergies
(e) Smoking
(f) Malignancy
(g) Clotting disorders
(h) Risk of pulmonary embolism
(i) Bronchiectasis - Scarring of the tissue
(j) Bronchitis
Personal and Social History
(a) Work-related exposure to irritants, allergens, and hazards should be explored. Use of protective devices should be documented.
(b) Tobacco use: Type of tobacco (cigarettes, cigars, pipe, smokeless)
(c) Environmental factors in the home include type of heating, air conditioning, and humidification.
(d) Use of herbal or other remedies, consistent with complementary/alternative therapies.
(e) Other relevant data include:
1) Drug and alcohol consumption
2) Exercise tolerance: Diminished ability to perform up to expectations
3) Travel history (particular areas with high TB infections).
4) Potential exposure to respiratory infections, such as influenza, or tuberculosis.
5) Nutritional status: Weight loss or obesity
6) Hobbies
7) Use of Alcohol or recreational drugs
a) Owning pigeons
b) Parrots or other animals
c) Woodworking
d) Welding
Hobbies: within Social Hx
Pack years is what
Number of years of smoking X Number of packs smoked per day
Tobacco use:
1) Duration and amount
2) Age started
3) Efforts to quit smoking with factors influencing success or failure.
4) The extent of smoking by others at home or at work (passive smoking).
In young adults describe sever, acute chest pain, ask about recreational drug use, particularly cocaine.
Fact
Cocaine can cause severe acute chest pain associated with a pneumothorax and other chest related conditions.
The sequence of steps in examination of the chest and lungs is traditional:
Tangential lighting is utilized to highlight chest movement. Or good lighting.
inspection, palpation, percussion, and auscultation.
Barrel chest (Fig. 14-9), results from compromised respiration as in, for example what diseases?
and characteristics of Barrel chest?
chronic asthma, emphysema, or cystic fibrosis.
2) The ribs are more horizontal, the spine is at least somewhat kyphotic, and the sternal angle is more prominent.
3) The AP diameter approaches or equals the lateral diameter (a ratio of 1.0 or even greater), there is most often a chronic condition present.
Clubbing of fingernails is indicative of
prolonged respiratory/cardiac distress.
Smell for odors of the breath
Sweet smell
diabetic ketoacidosis
Smell for odors of the breath
Ammonia
uremia
Smell for odors of the breath
Musty fish
hepatic failure
Smell for odors of the breath
Foul/feculent
intestinal obstruction/diverticulum
Smell for odors of the breath
Foul/putrid
respiratory infection (empyema, lung abscess, bronchiectasis)
Smell for odors of the breath
Halitosis
gingivitis, Vincent’s angina
Smell for odors of the breath
Cinnamon
tuberculosis
Normal rate and ratio of RR and HR
(a) Rate should be 12-20 respirations per minute
(b) Ratio of respirations to heartbeats is approximately 1:4
LOOK AT IT
Absence of spontaneous respirations.
Apnea-
the feeling or sensation that one cannot breath well enough. Distinct sensations include effort/work, chest tightness, and air hunger (the feeling of not enough oxygen)
Dyspnea-
Grave condition in which breathing stops and will not
spontaneously start again unless resuscitative measures are immediately instituted.
Secondary Apnea-
Shortness of breath that begins or increases when the patient lies down; ask whether the patient needs to sleep on more than one pillow and whether that helps.
Orthopnea-
A sudden onset of shortness of breathe after a
period of sleep; sitting upright is helpful.
Paroxysmal nocturnal dyspnea-
Dyspnea increase in the upright posture.
Platypnea-
A persistent respiratory rate faster than 20 and approaching 25 breaths per minute. (May be observed in those with metabolic acidosis).
Tachypnea-
A rate slower than 12 respirations per minute may indicate
neurologic or electrolyte disturbance, infection or a sensible response to protect against the pain of pleurisy (it may also indicate a splendid level of cardiorespiratory fitness).
Bradypnea-
A regular periodic pattern of breathing, with intervals of apnea followed by a crescendo/decrescendo (children and older adults may breath in this pattern during sleep, but it occurs in those with brain damage at the cerebral level or with drug- associated respiratory compromise).
Cheyne Stokes Respirations-
Somewhat irregular respirations varying in depth and
interrupted by intervals of apnea but lacking the repetitive pattern of periodic respirations of Cheyne Stokes.
Biot Respirations-
Respirations greater than 20, and deep (hyperventilation)
Hyperpnea-
Take note of Pectus Excavatum (Fig 14-12A) (Funnel Chest) and Pectus Carinatum (Fig 14.12B) (Pigeon Chest)
Look at it
