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Physical Assessment Review Study Guide Exam #1Know difference between subjective and objective data and examples of eachSubjective: what the person says about him/herself during history takingObjective: what the health professional observes by inspecting, palpating, percussing, and auscultating during the physical examKnow sections of a complete databaseComplete database: includes a complete health history and a full physical examination (as well as pt record and laboratory studies); describes the current and past health state and forms a baseline against which all future changes can be measured (yields the first diagnosis)For the healthy person:Describes the person’s health state, perception of health, strengths or assets such as health maintenance behaviors, individual coping patterns, support systems, current developmental tasks, and any risk factors or lifestyle changesFor the ill person:Also includes a description of the person’s health problems, perception of illness, and response to the problemsScreening for pathology and determine the response to the pathology (or any health problems)Used to refer pt to another professional, to help pt make decisions, and perform appropriate treatmentsNotes human response to health problemsCollect pts perception of illness, functional ability or patterns of living, ADLs, health maintenance behaviors, response to health problems, coping patterns, interaction patterns, and health goals All used to make a nursing diagnosisKnow a persons culture: how does it develop and basic characteristicsWhat are examples of first and second level priorities--difference between each levelFirst-level priority: those that are emergent, life threatening, and immediateEstablishing airway or support breathing, circulation (ABCs)Second-level priority: those that are next in urgency—requiring prompt interventions to forestall further deteriorationMental status changes, acute pain, acute urinary elimination problems, untreated medical problems, abnormal lab values, risk of infection, or risk to safety or securityWhat are the components of a health history and what types of data go in each section—examplesPresent health or history of present illness: Summary of symptomsLocation: specific; as person to point to the locationEx: pain behind the eyes; jaw pain, occipital painCharacter or quality: descriptive terms such as burning, sharp, dull, achingEx: “does the blood in the stool look like sticky tar?”Quantity or severity: quantify the symptom of pain using a scale; as how it affects their daily activitiesEx: “I was able to go to work, but them I came home and went to bed;” “I was so sick I was doubled up and couldn’t move.”Timing: onset, duration, frequencyInclude questions such as, How long did the symptoms last (duration), Was it steady (constant), Did it come and go (intermittent), Did it resolve completely or reappear days or weeks later (cycle of remission and exacerbation)Setting: where was the person, or what where they doing when symptoms started; what brought it onEx: “Did you notice the chest pain after shoveling snow, or did the pain start by itself?”Aggravating or relieving factors: What makes the pain worse; is it aggrevated by weather, activity, food, meds, standing bent over; fatigue; time of day; season… what relieves it; what are the effects of treatmentEx: “what have you tried,” or “what seems to help”Associated factors: is the primary symptom associated with any others? Is the symptom a side effect of a med or lifestyle factor (smoking)Ex: urinary frequency and burning associated with fever and chillsPatient’s perception: find out the meaning of the symptom by asking how it affects daily activities Past historyChildhood illnesses (MMR, chickenpox, pertussis, strep throat)Avoid recording usual childhood illnessesAccidents or injuriesSerious or chronic illnessesHospitalizationsOperationsObstetric historyImmunizationsLast exam dateCurrent medsAllergies and reactionFamily historyGenogramReview of systemsPurpose:Evaluate the past and present health state of each body systemDouble check in case any significant data were omitted in the Present Illness sectionTo evaluate health promotion practicesGeneral overall health state, skin, hair, head, eyes, ears, nose and sinuses, mouth and throat, neck, breast, axilla, respiratory, CV, PV, GI, GU, sexual health, musculoskeletal, neuro, hematologic, endocrineFunctional assessment (including ADLs)Measures a person’s self-care ability in the areas of general physical health or absence of illnessIADLs (instrumental ADLs): bathing, dressing, toileting, eating, walkingThose needed for independent living: housekeeping, shopping, cooking, laundry, telephone, finances, nutrition, relationshipsSections:Self-esteem, self-conceptEducation, financial status, value belief systemActivity/ExerciseAsk how they spend their typical day; ADLs and need for assistance; leisure activities; exercise patterns (amount, type, frequency)Sleep/restPatterns; naps; sleep aidsNutrition/elimination24hr recall and ask if it is typical; who buys food/prepared food; who is present during meal times; food allergies; daily intake of caffeine; bowel and urinary problems/frequency/habitsInterpersonal relationships/resourcesFamily role; how do they get along with family/friends/co-workers; support systemsSpiritual resourcesDoes religion play a role in their life, does it influence how they view health, are they part of a religious groupCoping and stress managementPersonal habitsAlcohol use/drug useEnvironment/hazards (living situation)Intimate partner violenceOccupational healthPerception of healthDefinition of healthDiscuss the interview process--what needs to be consideredWhat are the four physical assessment techniques--usual order, purpose of each, what is done in each section (exception to this order is the abdomen)Inspection: Initial “general survey” then inspect each body system without touchingLook for symmetryMust have good lighting, adequate exposure, and occasional use of instruments (otoscope, ophthalmoscope, light, specula)Palpation: Follows and confirms points noted during inspectionUse of touch to assess texture, temp, moisture, organ location and size, swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and presence of tenderness or painParts of hands used:Fingertips: best for fine tactile discrimination (skin texture, swelling, pulsation, lumps)Grasping with finger and thumb: detect position, shape, and consistence of an organ or massDorsa (back of hand): determining tempBase of fingers: vibrationsSlow and systematic; avoid sudden movements that will make the pt tense upPalpate tender areas lastLight palpation: done first to detect surface characteristicsDeep palpations: use intermittent pressure for abdominal contentsPercussion: Tapping the skin with short, sharp strokes to assess underlying structuresMapping out location and size of an organ (exploring where the percussion note changes between borders of organs)Density (air, fluid, or solid) of structuresDetecting abnormal masses that are fairly superficial (percussion only penetrated ~5cm (deeper masses would give no change in percussion)Eliciting pain if structures are inflamedEliciting deep tendon reflexes with percussion hammerPlexor strikes the pleximeterNotes:Resonant: clear, hollow; over normal lung tissueHyperresonant: Booming; normal over child’s lungs; abnormal in adults (hyperinflated lungs such as emphysema and COPD)Typany: musical and drum-like; over air-filled viscus (stomach and intestine)Dull: muffled thud; relatively dense organs (liver and spleen)Flat: dead stop of sound, absolute dullness; no air is present, over thigh muscle, bone, or over a tumorAuscultation: Stethoscope:Diaphragm: high-pitched sounds (breath, bowel, and normal heart sounds)Bell: low-pitched sounds (extra heart sounds, murmurs, BP)Discuss levels of hypertensionNormal:<120/<80Prehypertension:120-139/80-89No drugs indicatedHypertension (Stage 1):140-159/90-99Thiazide diuretics for most; may consider ACE inhibitors, ARBs, BB, CCB, or comboHypertension (Stage 2):>160/>100Two-drug combo for most; usually Thaizide and ACEI, or ARB, BB, CCBErrors in readingsFalsly high:Anxiety or angerArm below level of heartPerson supports arm (high diastolic)Legs crossedInaccurate cuff size (cuff too narrow)Deflating cuff too slowly (high diastolic)Repeating BP reading before 1-2min rest (high diastolic)Deflating cuff too quickly (high diastolic)Falsely low:Arm above heart levelNot inflating cuff above systolic BP (low systolic)Pushing stethoscope to hard (low diastolic)Deflating cuff too quickly (low systolic)Four areas of the general survey:Physical appearanceBody structureMobilityBehaviorMeasurementsBMI kg/m2Underweight <18.5Normal weight 18.5-24.9Overweight 25-29.9Obesity (class 1) 30-34.9Obesity (class 2) 35-39.9Extreme obesity (class 3) >40Waist circumferenceMen >40in or women >35in at risk for DM type 2, dyslipidemia, HTN, and CVD (with BMI b/t 25 and 35)Temp:Wait 15min after beverages; 2min after smokingOlder adults usually lower temp—mean of 36.2?C (97.2?F)Morning: 1-1.5?F variationMenstruation: 0.5-1.0?F riseHRNormal: 50-90bpm (conventional range is 60-100bpm)RR:Normal: 10-20 breaths/minFOR EACH OF THE FOLLOWING SYSTEMS—REVIEW HEALTH HISORY QUESTIONS FOR EACH AND POSSIBLE NURSING DIAGNOSESSKIN, PVS, and Lymphatic System (Ch. 12 & 20):Know anatomy and physiologyLayersEpidermis: Thin, tough protective barrier; avascularInner basal layer: forms new skin cells, contains melanocytes: skin color, and new skin cells become keratinized. Keratinized cells ? dead cellsOuter horny cell layer: layer of dead cells that packed closely and sheds constantly. extra (5th layer) on palms and solesKeratin (strength)PigmentMelanocytes (brown)Carotene (yellow-orange)Vascular beds (red-purple)Replaced every 4 weeks (shed 1lb of skin/year)Dermis: supportive layer; mostly connective tissue (collagen); contains nerves, sensory receptors, BVs, and lymphatics; appendages (hair follicles, sebaceous glands, and sweat glands)Subcutaneous: adipose tissue (fat for energy, insulation, and cushion)Function of skinIdentification/color: via melanin (brown), carotene (yellow?orange),Vascular bed (red?purple)General protection: microbes, physical, chemical, thermal, lightPrevents penetration: microbes enteringSensory & perception: feel things like temp, tactile, painTemp regulator: sweat for too hot, fat for too coldCommunication: nonverbal, blushingWound repair: scar tissueAbsorption & secretion: ex. topical meds % secrete oil/sweatVit D production + absorption: converts cholesterol to Vit D, SUNKnow order of physical examination and order of what is done in each section AND HOW IT IS DONEInspect and Palpate the Skin:Color: General pigmentation: observe skin tone; even and consistent with genetic background (freckles, moles)Widespread color changes: note any color change over the entire body skin, such as pallor (white); erythema (red), cyanosis (blue), and jaundice (yellow)Temperature:Note the temperature of your own handsUse the backs of your hands to palpate the person and check bilaterallySkin should be warm, and the temperature should be equal bilaterally; warmth suggests normal circulatory status; hands and feet may be slightly cooler Hypothermia: generalized coolness may be induced, such as in hypothermia used for surgery or high fever; localized coolness is expected with an immobilized extremity Hyperthermia: generalized hyperthermia occurs with an increased metabolic rate (fever) Moisture:Diaphoresis – profuse perspirationDehydration – oral mucous membranes; normally noneTexture:Normal skin feels smooth and firm, with an even surfaceThicknessEdema (1+, 2+, 3+, 4+)Mobility and TurgorVascularity or bruisingLesions (color, elevation, pattern/shape, size [cm]; location, any exudate) Inspect and Palpate the Hair:ColorHair color comes from melanin production and may vary from pale blonde to total blackTextureDistributionLesionsInspect and Palpate the Nails:Shape and Contour (normally slightly curved or flat; the profile sign)ConsistencyColorCapillary refillDescribe types of primary and secondary lesions—size and shapes—(e.g. bullae, papule, nodule; elliptical, linear shape)Primary lesion: lesion that develops on previously unaltered skinMacule: Color change, flat and circumscribed<1cmEx. Freckles, flat nevi, hypopigmentation, petehiae, measles, scarlet feverPatch: Macules >1cmEx. Mongolian spots, vitiligo, café au lait spot, chloasma, measles rashPapule: Solid, elevated, circumscribed lesion caused by superficial thickening in the epidermis<1cmEx. Elevated nevus, lichen planus, molluscum, wart (verruca)Plaque: Papules coalesce to form surface elevation; plaque-like, disk-shaped lesionWider than 1cmEx. Psoriasis, lichen planusNodule: Solid, elevated, hard or soft; may extend deeper into dermis than papule>1cmEx. Xanthoma, fibroma, intradermal neviWheal: Superficial, raised, transient, and erythematous; slightly irregular shape due to edemaEx. Mosquito bite, allergic reaction, dermographismTumor:Firm or soft, deeper into dermis; may be benign or malignant>few cmEx. Lipoma, hemangiomaUrticaria (Hives)Wheals coalesce to form extensive reaction; intensely pruriticVesicle:Elevated cavity containing free fluid; blisters; clear serum flows if wall is rupturedUp to 1cmEx. Herpes simplex, early varicella (chickenpox), herpes zoster (shingles), contact dermatitisBulla:Usually single chambered (unilocular); superficial in epidermis; thin walled; ruptures easily>1cmEx. Friction blisters, pemphigus, burns, contact dermatitisCyst:Encapsulated fluid-filled cavity in dermis or subq layer, tensely elevating skinEx. Sebaceous cyst, wenPustule:Turbid fluid (pus) in cavity; circumscribed and elevatedEx. Impetigo, acneSecondary lesion: lesion changes over time of changes because of a factor such as scratching or infectionCrust:Thickened, dried-out exudate left when vesicle/pustules burst or dry upColor red-brown, honey, or yellow depending on fluid ingredients (blood, serum, pus)Ex. Impetigo (dry, honey-colored), weeping eczematous dermatitis, scab after abrasionScale:Compact, desiccated flakes of skin, dry or greasy, silvery or white, from shedding of dead excess keratin cellsEx. After scarlet fever or drug reaction (laminated sheets), psoriasis (silver, mica-like), seborrheic dermatitis (yellow, greasy), eczema, ichthyosis (large, adherent, laminated), dry skinFissure:Linear crack with abrupt edges, extends into dermis, dry or moistEx. Cheilosis—at corners of mouth due to excess moisture; athlete’s footErosion:Scooped out but shallow depression; superficial; epidermis lost; moist but no bleeding; heals w/out scar b/c erosion does not extend into dermisUlcer:Deeper depression extending into dermis; irregular shape; may bleed; leaves scar when healsEx. Stasis ulcer, pressure sore, chancreExcoriation:Self-inflicted abrasion; superficial; sometimes crusted; scratches from itchingEx. Insect bite, scabies, dermatitis, varicellaScar:After a skin lesion is repaired, normal tissue is lost and replaced with connective tissue (collagen); permanent fibrotic changeEx. Healed area of surgery or injury, acneAtrophic scar:The resulting skin level is depressed with loss of tissue; a thinning of the epidermisEx. striaeLichenification:Prolonged, intense scratching eventually thickens the skin and produces tightly packed sets of papules; looks like surface moss (or lichen)Keloid:A hypertrophic scar; the resulting skin level is elevated by excess scar tissue, which is invasive beyond the site of original injury; may increase long after healing occurs; looks smooth, rubbery, and claw-like and has a higher incidence among BlacksKnow vascular lesions and markings (p. 238-240)Hemangiomas:Port-wine stain (Nevus Flammeus):Large, flat, macular patch covering scalp or face (freq. along distribution of CN V)Color: red, bluish, or purplish and intensifies with crying, exertion, or exposure to heat/coldConsists of macular capillariesPresent at birth; does not fadePhotoablation of lesion with yellow light lasersStrawberry mark (Immature Hemangioma):Raised bright red area with well-defined borders (2-3cm diameter)Non-blanchable w/ pressureConsists of immature capillariesPresent at birth or develops within first few months (disappears by age 5 to 7)Requires no TxCavernous hemangioma (Mature):Reddish blue, irregularly shaped, solid and spongy mass of blood vesselsMay be present at birth, enlargement in first 10-15 months, and will not involute spontaneouslyTelangiectases:Telangiectasia:Caused by vascular dilationPermanent enlargement and dilated BVs visible on skin surfaceSpider or Star Angioma:Fiery red, star-shaped marking with a solid circular cenerCapillary radiations extend from central arterial bodyWith pressure, note a central pulsating body and blanching of extended legsDevelops on face, neck, or chest May be associate w/ preg, chronic liver disease, or estrogen therapy, or may be normalVenous Lake:Blue-purple dilation of venules and capillaries in a star-shaped, linear, or flaring patternPressure causes them to empty or disappearLocated on legs near varicose veins; also on face, lips, ears, and chestPurpuric Lesions:Petechiae:Tiny punctate hemorrhages1-3 mm, round and discrete, dark red, purple, or brown in colorDue to bleeding from superficial capillaries (non blanching)Dark-skinned people, best visualized on area of lighter pigmentation (abdomen, butt, and volar surface of forearm)Petechiae in mucous membranes: disease process such as thrombocytopenia, subacute microembolism endocarditis, and other septicemias—not on skinPurpura:Confluent and extensive patch of petechiae and ecchymoses>3mm flat, red to purple, macular hemorrhageThrombocytopenia and scurvyOld age: minor trauma causing blood to leak from capillaries and diffuse through dermisEcchymosis:Purplish patch resulting from extravasation of blood into skin>3mm diameterKnow changes with aging process within these systemsSlow atrophy of skin structures (loses elasticity, folds, and sags)Epidermis’ outer layer thins and flattensAllows chemicals easier access to bodyDermis thins and flattens and wrinkling occursRisk of shearing and tearing injuries increases due to loss of collagenDecrease in sweat and sebaceous glandsDrier skinRisk for heat stroke (thermoregulatory mechanism—sweating—decreases)Senile Lentigines: liver spotsSmall, flat, brown maculesCircumscribed areas are clusters of melanocytes—appear after extensive sun exposure (forearms and dorsa of hands)—not malignant (no Tx)Keratoses: Raised, thickened areas of pigmentation; look crusted, scaly, and wartySeborrheic Keratosis: look dark, greasy, and “stuck on” – develop mostly on trunk, also on face and hands (non cancerous)Actinic (senile or solar) keratosis: less common; red-tan scaly plaques, become raised and roughened over years (directly related to sun exposure)—premalignant (may develop into squamous cell carcinoma)Xerosis: normal drying to aging (decline in sixe, number, and output of sweat and sebaceous glands)Skin itches and looks looseAcrochordons: skin tags; overgrowths of normal skin—form a stalk and are polyp-like (eyelids, cheeks, neck, axillae, and trunk)Sebaceous hyperplasia: raised yellow papules with a central depression; common in men; occur over forehead, nose, or cheeks (look pebbly)Hair grays due to decrease in functioning melanocytes (feel thin and fine)Know common abnormalities reviewed in PowerPoint’s and class discussions (e.g. vitiligo, neuropathy)What are the skin color variations (e.g. cyanosis, pallor, hyperemia)Benign pigmented areas:Freckles (ephelides): small, flat macules of brown melanin pigment that occur on sun-exposed skinMole (nevus): proliferation of melanocytes, tan to brown in color, flat or raisedCharacterized by symmetry, size (6mm or less), smooth borders, and single uniform pigmentationVitiligo: complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and orifices (dark skinned people more affected)Pallor: due to loss of oxygenated hemoglobin; skin takes color of collagen Acute stress states (anxiety) due to peripheral vasoconstrictionCold or cigarette smokingEdemaLook for pallor in dark-skinned people by the absence of underlying red tones that give brown or black skin its lusterBrown skin appears yellowish brownBlack skin appears ashen or grayAshen gray in dark skinned or marked pallor in light skinned occurs with anemia, shock, arterial insufficiencyPallor with shock presents with rapid HR, oliguria, apprehension, and restlessnessIron deficiency anemia may show spoon nailAnemia presents with fatigue, exertional dyspnea, rapid pulse, dizziness, and impaired mental functionGeneralized pallor observed in mucous membranes, lips and nail bedsNail beds and conjunctiva (near outer canthus) are the preferred sites for assessing pallor of anemiaErythema: intense redness of skin from excess blood (hyperemia) in the dilated superficial capillariesFever, local inflammation, or emotional reactions (blushing of cheeks, neck, or upper chest)Fever and inflammation increases skin temp due to rate of blood flowPalpate dark-skinned people for increased warmth, taut or tightly pulled surfaces that are indicative of edema, and hardened deep tissue or BVs (erythema may not be visual)Occurs with polycythemia, venous stasis, CO poisoning, and extravascular presence of RBCs (petechiae, ecchymosis, hematoma)Cyanosis: bluish mottled color signifying decreased perfusion (low tissue O2 blood)Can be nonspecificAnemia with hypoxemia can present without cyanosis due to low hemoglobin (won’t color skin)Polycythemia produces ruddy blue at all times and may not necessarily be hypoxemicDark-skinned Mediterranean people commonly have bluish tone on lipsIndicated hypoxemia and occurs with shock, HF, chronic bronchitis, and congenital heart diseaseSigns of decreased O2 to brain, changes in LOC, and respiratory distressJaundice: indicates rising amount of bilirubin in the bloodNoticeable first in hard and soft palate of mouth and scleraDark-skinned people may have normal yellow subconjunctival fatty deposits in outer scleraYellow of jaundice extends up to the edge of the irisBecomes evident on skin of body as serum levels of bilirubin riseBest assessed in direct natural lightOccurs with hepatitis, cirrhosis, sickle-cell disease, and hemolytic disease of newbornsLight or clay-colored stools and dark golden urine often accompany jaundice in both light and dark-skinned peopleSkin cancer examinations—ABCDEAsymmetry: not regularly round or oval, two halves of lesion do not look the sameBorder irregularities: notching, scalloping, ragged edges, poorly defined marginsColor variations: areas of brown, tan, black, blue, red, white, or comboDiameter: greater than 6mm (size of a pencil eraser)Elevation or Enlargement: Additional symptoms: rapidly changing lesion, new pigmented lesion, and development of itching, burning, or bleeding in a mole (raise suspicion of malignant melanoma)Differentiate: senile lentigines, actinic keratoses, squamous cell carcinoma, basal cell carcinoma, and seborrheic keratosisSenile lentigines: Liver SpotsSmall, flat, brown maculesCircumscribed areas are clusters of melanocytes—appear after extensive sun exposure (forearms and dorsa of hands)—not malignant (no Tx)Actinic keratosis: Red-tan scaly plaques, become raised and roughened over years (directly related to sun exposure)—premalignant (may develop into squamous cell carcinoma)Squamous cell carcinoma: Arises from actinic keratosis or denovoErythematous scaly patches with sharp margins> 1cmDevelops central ulcer and surrounding erythemaUsually on hands or head, areas of UV exposure; habitually sub-exposed bald scalpLess common than basal cell carcinoma (grows rapidly)Basal cell carcinoma: Usually starts as a skin-colored papule (may be deeply pigmented) with pearly translucent top and overlying telangiectasia (blood broken vessels)Develops rounded, pearly borders with central red ulcer (large open pore with central yellowing)Most common form a skin cancer (slow but inexorable growth)Sun exposed face, ears, scalp, shouldersSeborrheic keratosis: Look dark, greasy, and “stuck on” – develop mostly on trunk, also on face and hands (non cancerous)Malignant Melanoma:Arise from preexisting nevi (usually)Usually brown; can be tan, black, pink-red, purple, or mixed pigmentationIrregular notched bordersMay have scaling, flaking, oozing textureLocations:Trunk and back in men and womenLegs in womenPalms, soles of feet, and nails in BlacksDifferentiate arterial and venous peripheral vascular disease –acute and chronic: pain:---noting symptom analysis. (p. 521 in text)Arterial: s/s of oxygen deficitChronic Arterial:Location: Deep muscle pain, usually in calf, but may be lower leg or dorsum of footCharacter: Intermittent claudication, feels like “cramping,” “numbness and tingling,” “feeling of cold”Onset and Duration: Chronic pain, onset gradual after exertionAggravating Factors: Activity (walking, stairs); “claudication distance” is specific number of blocks, stairs it takes to produce pain; elevation (rest pain indicates severe involvement)Relieving Factors: Rest (usually within 2min [ex. Standing]); dangling (severe involvement)Associated Symptoms: Cool, pale skinThose at Risk: Older adults, males > females; inherited predisposition; Hx of HTN, smoking, DM, hypercholesterolemia, obesity, vascular diseaseAcute Arterial:Location: Varies, distal to occlusion, may involve entire legCharacter: throbbingOnset and Duration: sudden onset (within 1hr)Aggravating Factors: Relieving Factors: Associated Symptoms: Six Ps: pain, pallor, pulselessness, paresthesia, poikilothermia (coldness), paralysis (indicates severe)Those at Risk: Hx of vascular surgery; arterial invasive procedure; abdominal aneurysm (emboli); trauma, including injured arteries; chronic atrial fibrillationVenous: s/s of metabolic waste buildupChronic Venous:Location: calf, lower legCharacter: aching, tiredness, feeling of fullnessOnset and Duration: chronic pain, increases at end of dayAggravating Factors: prolonged standing, sittingRelieving Factors: elevation, lying, walkingAssociated Symptoms: edema, varicosities, weeping ulcers at anklesThose at Risk: job with prolonged standing or sitting; obesity; pregnancy; prolonged bed rest; Hx of HF, varicosities, or thrombophlebitis; veins crushed by trauma or surgeryAcute Venous:Location: calfCharacter: intense, sharp; deep muscle tender to touchOnset and Duration: sudden onset (within 1hr)Aggravating Factors: pain may increase with sharp dorsiflexion of footRelieving Factors: Associated Symptoms: red, warm, swollen legThose at Risk: Describe arterial pulses—variations in pulse contour–and grading systemTemporal: palpated in front of the earCarotid: palpated in the groove b/t the sternomastoid muscle and tracheaBrachial: runs in the biceps-triceps furrow of upper arm and surfaces at the antecubital fossa in the elbow medial to the biceps tendonBoth should be equalUlnar: medial to the ulna; deeper and often difficult to feelRadial: medial to radius at the wrist3+: increased, full, bounding (exercise, anxiety, fever, anemia, hyperthyroidism)2+: normal1+: weak (shock and PAD)0: absentModified Allen test: evaluate the adequacy of collateral circulation before cannulating the radial arteryFirmly occlude both ulnar and radial arteries (11lbs of pressure) while person makes a fist several times (causes hands to blanch)Person opens hand without hyperextending itRelease pressure on the ulnar artery while maintaining pressure on the radial arteryPalm should blush with adequate circulationPallor or sluggish return suggests occlusion of the collateral artery flowFemoral: just below the inguinal ligament halfway b/t the pubis and anterior superior iliac spine (to assess, have person bend knee to the side—froglike position)Press firmly and release slowly—note pulse tapIf pulse is weak or diminished, auscultate for bruitBruit occurs with turbulent blood flow—indicates partial occlusionPopliteal: lower thigh behind kneePalpate by extending the leg (but relaxed), anchor thumb on knee and curl fingers around popliteal fossa; press fingers forward hard to compress artery against the boneDorsalis pedis: dorsum of footPosterior tibial: travels down behind the medial malleolusAnkle-Brachial Index (ABI):Ankle systolic / Arm systolic = ____%Normal 1.0 – 1.02< 0.90 indicates PAD0.90 – 0.70: mild claudication0.70 – 0.40: moderate to severe claudication0.40 – 0.30: severe claudication, usually with rest pain except in the presence of diabetic neuropathy<0.30: ischemia, with impending loss of tissuePulse Contour:1+ (weak, thready pulse)Hard to palpate, need to search for it, may fade in and out, easily obliterated by pressureAssociated with decreased CO, peripheral arterial disease, aortic valve stenosis3+ (full, bounding)Easily palpable, pounds under fingertipsAssociated with hyperkinetic states (exercise, anxiety, fear), anemia, hyperthyroidism3+ (water-hammer – Corrigan)Greater than normal force, then collapses suddenlyAssociated with aortic valve regurgitation, patent ductus arteriosusPulsus Gigeminus:Rhythm is coupled, every other beat comes early, or normal beat followed by premature beat; force of premature beat is decreased because of shortened cardiac filling timeAssociated with conduction disturbance (PVCs, PACs)Pulsus Alternans:Rhythm is regular, but force varies with alternating beats of large and small amplitudeWhen HR is normal, pulsus alternans occurs with severe left vent failure, which in turn is due to ischemic heart disease, valvular heart disease, chronic hypertension, or cardiomyopathyPulsus Paradoxus:Beats have weaker amplitude with inspiration, stronger with expiration; best determined during BP measurements; reading decreases (>10mmHg) during inspiration and increases with expirationA common finding in cardiac tamponade (pericardial effusion in which high pressure compresses the heart and blocks CO); also in severe bronchospasms of acute asthmaPulsus BisferiensEach pulse has two strong systolic peaks, with a dip in between; best assessed at the carotid arteryAssociated with aortic valve stenosis plus regurgitationDescribe lymph nodes examined—and if felt how are they analyzedCervical nodes: drain the head and neckAxillary nodes: drain the breast and upper armsEpitrochlear nodes: lie in the antecubital fossa (depression above and behind the medial condyle of the humerus) and drain the hand and lower armAssess by shaking hands with the person and reaching your other hand under the person’s elbow to the groove b/t the biceps and triceps muscles (above the medial condyle)Not palpable normallyEnlargement signifies infection of hand or forearm; generalized lymphadenopathy (lymphoma, chronic lymphocytic leukemia, sarcoidosis, infection, mononucleosis)Inguinal nodes: located in the groin and drain most of the lymph of the Les, external genitalia, and the anterior abdominal wallNot unusual to find palpable nodes that are small (1cm or less), moveable, and nontenderAbnormal: enlarged, tender, or fixed in areaDescribe signs/symptoms of:Lymphedema: High-protein swelling of the limbs (commonly due to breast cancer Tx)Surgical removal of lymph nodes or damage to nodes and vessels with radiation impedes drainage of lymph (protein rich lymph builds up in interstitial spaces, further raising local colloid oncotic pressure—promotes more fluid leakage)Stagnant lymphatic fluid increases risk for infection, delayed wound healing, chronic inflammation, and fibrosis of surrounding tissueEarly symptoms: tired, thick, heavy arm (self-reported); jewelry too tight; swelling; tinglingObjective data: unilateral swelling, non-pitting brawny edema, with overlying skin indurationClaudication: Venous insufficiency: Raynauds disease: Episodes of abrupt, progressive tricolor change of the fingers in response to cold, vibration, or stressProgression: white (pallor) due to arteriospasm and resulting deficit in supply; cyanosis from slight relaxation of the spasm that allows a slow trickle of blood through the capillaries and increased oxygen extraction of hemoglobin; red (rubor) in heel of hand due to return of blood into the dilated capillary bed or reactive hyperemiaS/S: cold, numbness, or pain along with pallor or cyanosis stage; then burning, throbbing pain, swelling, along with rubor; lasts minutes to hrs.; occurs bilaterally; smoking and drugs can increase symptomsDVT: Thrombus that causes inflammation, blocked venous return, cyanosis, and edemaSubjective: sudden onset of intense, sharp, deep muscle pain; may increase with sharp dorsiflexion of footObjective: Increased warmth; swelling; redness; dependent cyanosis is mild or may be absent; tender to palpation; positive Homan’s in some casesVenous stasis ulcer: Usually at medial malleolus (due to bacterial invasion of poorly drained tissues); occur after DVT or chronic incompetent valves in deep veinsSubjective: Aching pain in calf or lower leg; worse at end of day; worse with prolonged standing or sittingObjective: Firm, brawny edema; coarse, thickened skin; pulses normal; brown pigment discoloration (RBC breakdown, leaving hemosiderin [iron deposits]); petechiae; weepy, pruritic stasis dermatitis may be presentArterial ischemic ulcer: Usually occurs on tips of toes, metatarsal heads, heals, and lateral malleoli of ankles (pale ischemic base, well-defined edges, no bleeding)Unilateral cool foot or leg or a sudden temperature drop as you move down the leg occurs with arterial deficitBuildup of fatty plaques on intima (atherosclerosis) plus hardening and calcification of arterial wall (arteriosclerosis)Subjective: deep muscle pain in calf or food, claudication (pain with walking), pain at rest indicates worsening of conditionObjective: coolness, pallor, elevation pallor, and dependent rubor; diminished pulses; systolic bruits; signs of malnutrition (thin, shiny skin; thick-ridged nails; atrophy of muscles); distal gangreneVaricose veins: Incompetent valves permit reflux of blood, producing dilated, tortuous veinsSubjective: Aching, heaviness in calf, easy fatigability, night leg or food crampsObjective: Dilated, tortuous veinsChanges noted with diabetes: Hastens changes described with ischemic ulcer, with generalized dysfunction in all arterial areas:Peripheral (diabetic neuropathy), coronary, cerebral, retina, kidneyUlcers may go unnoticedPain and sensation are decreased, surrounding skin is callousedTHORAX/LUNGS (Ch. 18):Know anatomy and physiologyAngle of Louis: second rib and second ICSVertebra Prominens: C7Costal angle (anterior): 90?Inferior angle of scapula: posterior ribs 7 or 8Right lung: 3 lobesLeft lung: 2 lobesLeft lung has no middle lobeAnterior chest contains mostly upper and middle lobe with very little lower lobePosterior chest contains almost all lower lobeTracheal bifurcation: anteriorly at sternal angle; posteriorly at level of T4 or T5Know order of physical examination and order of what is done in each section AND HOW IT IS DONESubjective data:Couch Acute lasts 2-3 wks.Continuous throughout day (resp infection)Afternoon/evening (chem exposure)Night (postnasal drip, sinusitis)Chronic >2monthsMorning (chronic bronchial inflammation of smokers)Chronic bronchitis (Hx of productive cough for 3months of the year for 2yrs)HemoptysisSputumWhite or clear: colds, bronchitis, viral infectionYellow or green: bacterial infectionRust colored: TB, PNAPink, frothy: pulmonary edema; sympathomimetic medsCharacteristics:Hacking: mycoplasma PNADry: early HFBarking: croupCongested: colds, bronchitis, PNASOBDetermine level of activity that precipitates SOB (# of blocks walked or stairs climbed)Orthopnea: difficulty breathing when supine (# of pillows needed to achieve comfort)Paroxysmal nocturnal dyspnea (awakening from sleep with SOB—need to be upright to achieve comfortDiaphoresis; cyanosis signals hypoxiaAsthma attack and precipitating factor (allergens, extreme cold, anxiety)Assess coping strategies and need for teachingAsses ADLs and its affect on themCPCP of thoracic origin occurs with muscle soreness from coughing or inflammation of pleura overlying PNA (distinguish from other causes—cardiac or heartburn)Hx of resp infectionsSmoking: state number of packs per year and # of years smokingEnvironment exposure: pollution; farmers at risk for grain inhalation and pesticidesSymptoms: cough, SOB; CO exposure = dizziness, HA, fatigue; Sulfur dioxide = cough, congestionSelf care: flu vaccine; TB testObjectivePosterior thorax:Inspection:Thoracic cage:Shape and configuration Spinous process should appear in a straight line; thorax symmetric, elliptical shape, downward sloping ribs, 45? relative to spine; scapulae placed symmetrically in each hemithroaxAP diameter < transverse diameter (1:2 or 5:7)Neck muscles and traps developed normally for age and occupation (hypertrophy in COPD)PositionRelaxed posture with arms comfortably at side or in lapCOPD = tripod (arms on knees and leaning forward—allows for aid from rectus abdomins, intercostals, and accessory muscles)Skin color and conditionConsistent with genetic background; no cyanosis or pallorPalpation:Confirm symmetric expansion: hands placed on posterolateral chest walls with thumbs at the level of T9 or T10 (small fold of skin pinched b/t thumbs)Unequal occurs with marked atelectasis, lobar PNA, pleural effusion; fractured ribs; pneumothoraxPain with inflammation of pleuraeTactile fremitus:Palpable vibrationUse palmar base of fingers or ulnar edge while pt repeats 99 or blue moonStart at apex of lungs from one side to the otherLook for symmetryBetween scapulae-may feel stronger on right side (closer to bronchial bifurcation)Fremitus normally decreases from scapulae (bronchi close to chest wall) downward due to more tissue massTake into account size of pt and pitch of voice (low pitch = more fremitus)Decreased fremitus: obstruction (obstructed bronchus, pleural effusion or thickening, pneumothorax, or emphysema)Increased fremitus: compression or consolidation of lung tissue (lobar PNA) when bronchus is patent and consolidation extends to lung surfaceRhonchal fremitus: thick bronchial secretionsPleural friction fremitus: inflammation of the pleuraCrepitus: coarse, crackling sensation palpable over skin surface (subcutaneous emphysema—air escapes lungs and enters subQ tissue or after open thoracic injury or surgery)Palpate for tenderness, moisture, temp, lumps or masses, lesionsPercussion:Percuss in 5cm intervals avoiding boneResonance: low-pitched, clear, hollow sound in healthy lungsHyperresonance: low-pitched booming sound with too much air present (emphysema or pneumothorax)Dull: soft, muffled signals abnormal density with PNA, pleural effusion, atelectasis, or tumorsPercussion notes must be 2-3cm wide to yield abnormalityPercussion only penetrates 5-7cm deepDiaphragmatic excursion: map by percussing lower lung border (inspiratory and expiratory)Percuss on exhalation down scapular line until you hear dullness – may be higher on right side (1-2cm) due to liverPercuss on inhalation and continue percussing to dullness and markExcursion should be 3-5cm bilaterally (may ne 7-8cm in well conditioned person)Absence of excursion in pleural effusion or atelectasis of lower lobesAuscultation:Use diaphragm to listen to full respiration in each locationLocations:Posterior: apex to C7 to bases (around T10)Lateral: axilla to 7th or 8th ribAnterior thorax:Inspect:Shape and configRibs sloping downward with symmetric ICSCostal angle ≤90?Barrel chest >90? costal angle Normal development of abdominal musclesHypertrophy occurs with emphysemaFacial expressionRelaxed and benign, indicating unconscious breathingCOPDTense, strained, tired face Pursed lips allowing air to be exhaled slowly—narrow opening creates pressure in bronchial tree and fewer airways collapseLOC:AAOx4Skin color and conditionNail beds free of cyanosis and pallor; normal configurationClubbing of distal phalanx occurs with chronic respiratory diseaseNo lesionsCutaneous angioms (spider nevi) associated with liver disease or portal HTN may be evident on chestRespirations (quality): automatic and effortless, regular, even, no noise; symmetrical expansion of chest during inspiration; no lag on inspirationNoisy=asthma or chronic bronchitisUnequal expansion occurs when part of lung is onstructed or collapsed (PNA) or when guarding to avoid postop incisional pain or pleurisy painRetractionsNo presence on inspirationSuggest obstruction of resp tract or increased inspiratory effort (at with atelectasis)Bulging indicates trapped air as in the forced expiration with emphysema or asthmaPalpateSymmetric expansion:Hands on anterolateral wall with thumbs along costal margin, pointing inward toward xiphoid process (symmetrical expansion on inspiration)Emphysema: wide costal angle with little inspiratory variationAtelectasis, PNA, postop guarding: lag in expansion Tactile fremitusBegin at apex and repeat 99Female breast tissue dampens soundPalpate chest wall for tenderness, lumps and masses, skin turgor, temp, moisturePercussionBegin at apices (supraclavicular) continuing down within ICSNote borders of cardiac dullnessLiver: dullness in 5th ICS in the right midclavicular lineTympany over left gastric spaceAuscultateForced expiratory time: should be ≤4sec (≥6sec = obstructive lung diseaseKnow changes with aging process within these systemsCostal cartilage becomes calcified—produces a less mobile thoraxResp muscle strength decreases after age 50 and continues to decrease into 70sLungs decrease in elasticity (less distensible and lessening their tendency to collapse and recoilMore ridged and harder to inflateIncrease in small airway closure (decreased vital capacity—max volume of air expelled after maximum filling)Increased residual volume (amount of air remaining in lungs after forced expiration)Gradual loss of intraalveolar septa and decreased number of alveoli (less surface are for gas exchange)Less ventilation with closure of airways—increased risk for dyspnea with exertion Increased risk for pulmonary postop complications (atelectasis and infection—decreased ability to cough, a loss of protective airway reflexes, and increased secretions)DESCRIBE “NORMAL LUNG SOUNDS”—VESICULAR, BRONCHOVESICULAR, BRONCHIAL and where should they be heardBronchial: pitch high, amplitude loud; duration: inspiration > expiration; quality harsh, hollow, tubular; Location: trachea and larynxBronchovesicular: pitch and amplitude moderate; duration: inspiration = expiration; quality mixed; location over bronchi where fewer alveoli are located; posterior b/t scapulae especially on right, anterior around upper sternum in 1st and 2nd ICSVesicular: pitch low; amplitude soft; duration: inspiration > expiration; quality: rustling like the sound of wind in trees; location over peripheral lung fields where air flow through smaller bronchioles and alveoliDescribe added voice sounds and adventitious lung sounds—when may you hear them—what conditionsVoice sounds (should be soft, muffled, and indistinct—pathology that increases lung density enhances transmission of voice sounds) – normally used if lung pathology is suspected- not routineBronchophony: ask the person to repeat “ninety-nine” while you listen with the stethoscope over the chest wall; listen especially if you suspect pathologyNormal finding: normal voice transmission is soft, muffled, and indistinct; you can hear sound through the stethoscope but cannot distinguish exactly what is being saidAbnormal finding: pathology that increases lung density will enhance transmission of voice sounds; you can auscultate a clear “ninety-nine”; the words are more distinct than normal and sound close to your earEgophony: auscultate the chest while the person phonates a long “ee-ee-ee-ee” sound Normal finding: normally, you should hear “eeeee” through stethoscopeAbnormal finding: over area of consolidation or compression, the spoken “eeee” sound changes to a bleating long “aaaa” soundWhispered Pectoriloquy: ask the person to whisper a phrase like “one-two-three” as you auscultateNormal finding: the normal response is faint, muffled, and almost inaudibleAbnormal finding: with only small amounts of consolidation, the whispered voice is transmitted very clearly and distinctly, although still somewhat faint; it sounds as if the person is whispering right into your stethoscope, “one-two-three”Adventitious sounds:Discontinuous Sounds: those that are discrete, crackling soundsCrackles – fine (formerly called rales): discontinuous, high-pitched, short crackling, popping sounds heard during inspiration that are not cleared by coughingClinical ex: pneumonia, CHF, COPDCrackles – coarse (coarse rales): loud, low-pitched bubbling and gurgling sounds that start in early inspiration and may be present in expiration; may decrease somewhat by suctioning or coughing but will reappear shortlyClinical ex: pulmonary edema, pneumonia, pulmonary fibrosisAtelectatic crackles: short, popping, crackling sounds that sound like fine crackles but do not last and are not pathologic; disappear after first few breaths or a cough; heard in periphery (dependent portions of lungs)Clinical ex: aging adults; bedridden persons or in persons just aroused from sleepPleural friction rub: a very superficial sound that is coarse and low pitched; it has a grating quality as if two piece of leather are being rubbed together; sounds just like crackles, but close to the ear; sounds louder if you push the stethoscope harder onto chest wall Clinical ex: pleuritis, accompanied by pain with breathing (rub disappears after a few days if pleural fluid accumulates and separates pleurae)Continuous Sounds: these are connected, musical soundsWheeze – high pitched: high-pitched, musical squeaking sounds that sound polyphonic; predominant in expiration but may occur in bothClinical ex: diffuse airway obstruction from acute asthma or chronic emphysemaWheeze – low-pitched: low-pitched; monophonic single note, musical snoring, moaning sounds; heard throughout the cycleClinical ex: bronchitis, single bronchus obstruction from airway tumorStridor: high-pitched, monophonic, inspiratory, crowing sound, louder in neck than over chest wallClinical ex: coup and acute epiglottitis in children, and foreign inhalation, obstructed airway may be life-threateningDescribe respiratory patterns and in what conditions may they be heard Normal Adult: Rate: 10-20 breaths per minuteDepth: 500-800mLPattern: evenThe ratio of pule to respirations is fairly constant, about 4:1, both values increase as a normal response to exercise, fear, or feverDepth: air moving in and out with each respirationSigh: occasional sighs punctuate the normal breathing pattern and are purposeful to expand alveoli; frequent sighs may indicate emotional dysfunction; may also lead to hyperventilation and dizzinessTachypnea: rapid, shallow breathing; increased rate, >24 per minute; normal response to fever, fear, or exercise; rate also increases with respiratory insufficiency, pneumonia, alkalosis, pleurisy, and lesions in the pons Hyperventilation: increase in both rate and depth; normally occurs with extreme exertion, fear, or anxietyDKAHepatic comaSalicylate overdoseAlteration in blood gas concentrationBlows off CO2 causing a decreased level in the bloodBradypnea: slow breathing; a decreased but regular rate (<10 per minute)Drug induced depressionIncreased ICPDiabetic comaHypoventilation: irregular shallow pattern caused by an overdose of narcotics or anesthetics; may also occur with prolonged bedrest or conscious splinting of the chest to avoid respiratory painCheyne-Stokes Respiration: a cycle in which respirations gradually wax and wane in a regular pattern, increasing in rate and depth and then decreasing; lasts 30-45 seconds with periods of apnea (20 seconds) alternating the cycleSevere heart failureRenal failureMeningitisDrug overdoseIncreased ICPOccurs normally in infants and aging persons during sleepBiot’s Respiration: similar to Cheyne-Stokes, except that the pattern is irregular; a series of normal respirations is followed by a period of apneaHead traumaBrain abscessHeat strokeSpinal meningitisEncephalitisChronic Obstructive Breathing: normal inspiration and prolonged expiration to overcome increased airway resistanceCOPDAny situation calling for increased heart rate (exercise) may lead to dyspneic episode (air trapping) because the person does not have enough time for full expirationDescribe signs and symptoms associated with COPD, bronchitis, emphysema, pulmonary effusion, sarcoidosis, consolidation, pulmonary embolism, atelectasis, asthma, lobar pneumonia, pneumothorax, tuberculosis ARDS-acute respiratory distress syndromeChronic Obstructive Pulmonary Disease (COPD): Bronchitis: proliferation of mucus glands in the passageways, resulting in excessive mucus secretion; inflammation of bronchi with partial obstruction of bronchi by secretions or constrictionsInspection: hacking, rasping cough productive of thick mucoid sputumPalpation: tactile fremitus normalPercussion: resonantAuscultation: normal vesicular; voice sounds normalAdventitious sounds: crackles over deflated areas, may have wheezeEmphysema: caused by destruction of pulmonary connective tissue; characterized by permanent enlargement of air sacs distal to terminal bronchioles; hyperinflated lungInspection: increased AP diameter (barrel chest); use of accessory muscles to aid respiration; tripod position; SOB, especially on exertionPalpation: decreased tactile fremitus and chest expansionPercussion: hyperresonant, decreased diaphragmatic excursion Auscultation: decreased breath sounds; may have prolonged expiration; muffled heart sounds resulting from overdistention of lungsAdventitious sounds: usually none; occasionally wheezePulmonary Effusion: collection of excess fluid in the intrapleural space, with compression of overlying lung tissue; may contain watery capillary fluid, protein, purulent matter, blood, or milky lymphatic fluidInspection: increased respirations, dyspnea; may have dry couch, tachycardia, cyanosis, abnormal distentionPalpation: tactile fremitus decreased or absent; tracheal shift away from affected side; chest expansion decreased on affected sidePercussion: dull to flat; no diaphragmatic excursion on affected sideAuscultation: breath sounds decreased or absent; voice sounds decreased or absent; when remainder of lung is compressed near effusion, may have bronchial breath sounds over the compressionAdventitious sounds: noneSarcoidosis: Consolidation: Pulmonary Embolism: undissolved materials originating in legs or pelvis detach and travel through venous system returning blood to right heart and lodge to occlude pulmonary vesselsSubjective: chest pain, worse on deep inspiration, dyspneaInspection: apprehensive, restless, anxiety, mental status changes, cyanosis, tachypnea, cough, hemoptysis, PaO2 <80% on pulse ox, ABGs show respiratory alkalosisPalpation: diaphoresis, hypotensionAuscultation: tachycardia, accentuated pulmonic component of S2 heart soundAdventitious sounds: crackles, wheezes Atelectasis (Collapse): collapsed shrunken section of alveoli or an entire lung as a result of 1. Airway obstruction 2. Compression on the lung 3. Lack of surfactant Inspection: cough; lag on expansion on affected side; increased respiratory rate and pulse; possible cyanosisPalpation: chest expansion decreased on affected side; tactile fremitus decreased or absent over area; with large collapse, tracheal shift toward affected sidePercussion: dull over area (remainder of thorax sometimes may have hyperresonant note)Auscultation: breath sounds decreased vesicular or absent over area; voice sounds variable, usually decreased or absent over affected areaAdventitious sounds: none if bronchus is obstructed; occasional fine crackles if bronchus is patentAsthma: an allergic hypersensivity to certain inhaled allergens, irritants, microbes, stress, or exercise that produces a complex response characterized by bronchospasm and inflammationInspection: during severe attack: increased respiratory rate, SOB with audible wheeze, use of accessory neck muscles, cyanosis, apprehension, retraction of intercostal spaces, expiration labored, prolonged; when chronic, may have barrel chestPalpation: tactile fremitus decreased, tachycardiaPercussion: resonant; may be hyperresonant if chronicAuscultation: diminished air movement; breath sounds decreased, with prolonged expiration, voice sounds decreasedAdventitious sounds: bilateral wheezing on expiration, sometimes inspiratory and expiratory wheezing Lobar Pneumonia: infection in lung parenchyma leaves alveolar membrane edematous and porous, so RBCs and WBCs pass from blood to alveoliInspection: increased respiratory rate; guarding and lag on expansion on affected side; children – sternal retraction, nasal flaringPalpation: chest expansion decreased on affected side; tactile fremitus increased if bronchus patent; decreased if bronchus obstructedPercussion: dull over lobar pneumoniaAuscultation: breath sounds louder with patent bronchus, voice sounds have increased clarityAdventitious sounds: crackles, fine to mediumPneumothorax: free air in pleural space causes partial or complete lung collapse; spontaneous, traumatic, or tensionInspection: unequal chest expansion; if large, tachypnea, cyanosis, apprehension, bulging in interspacesPalpation: tactile fremitus decreased or absent; tracheal shift to opposite side (unaffected side); chest expansion decreased on affected side; tachycardia, decreased BPPercussion: hyperresonant; decreased diaphragmatic excursionAuscultation: breath sounds decreased or absent; voice sounds decreased or absentAdventitious sounds: noneTuberculosis: Subjective: initially asymptomatic, showing as positive skin test or on x-ray film; progressive TB involves weight loss, anorexia, easy fatigability, low-grade afternoon fevers, night sweats; may have pleural effusion, recurrent lower respiratory infectionsInspection: cough initially nonproductive; later productive of purulent, yellow-green sputum, may be blood tinged; dyspnea, orthopnea, fatigue, weaknessPalpation: skin moist at night from night sweatsPercussion: resonant initially; dull over any effusionAuscultation: normal or decreased vesicular breath soundsAdventitious sounds: crackles over upper lobes common, persist following full expiration and coughAcute Respiratory Distress Syndrome (ARDS): an acute pulmonary insult damages alveolar capillary membrane, leading to increased permeability of pulmonary capillaries and alveolar epithelium and to pulmonary edema Subjective: acute onset of dyspnea, apprehensionInspection: restlessness; disorientation; rapid, shallow breathing; productive cough, thin, frothy sputum; retractions of intercostal spaces and sternum; decreased PaO2, blood gases show respiratory alkalosis, x-ray films show diffuse pulmonary infiltrates, a late sign is cyanosisPalpation: hypotensionAuscultation: tachycardiaAdventitious sounds: crackles, rhonchi Know causes for increased and decreased breath soundsBreath sounds:Decreased:Bronchial tree obstruction by secretions, mucus plug, or foreign bodyEmphysema as a result of loss of elasticity in lung fibers and decreased force of inspired air; lungs are already hyperinflated so inhaled air does not make much noiseWhen anything obstructs transmission of sound b/t lungs and stethoscope (pleurisy or pleural thickening, or air [pneumothorax] or fluid [pleural effusion] in pleural spaces)Increased:Sounds are louder then they should be (bronchial sounds are abnormal when heard in peripheral lung fields—high pitched tubular quality, with prolonged expiratory phase and a distinct pause b/t inspiration and expiration)Sound very close to stethoscope as if they were right in the tubing of your earOccur when consolidation (PNA) or compression (fluid in intrapleural space) yields a dense lung area that enhances the transmission of sound from the bronchiKNOW LINES OF REFERENCE for each section: ANTERIOR, POSTERIOR, AND AXILLARYAnterioor:Midclavicular line: midpoint between sternoclavicular and acromioclavicular jointsMidsternal line: sternumPosterior:Vertebral (midspinal) line: vertebraeScapular line: aligns with inferior angle of scapulaLateral:Anterior axillary: extends down from the anterior axillary fold where the pectoralis major insertsMidaxillary: Between anterior and posteriorPosterior axillary: continues down from where the latissimus dorsi muscle insertsKNOW LOBES OF LUNGS—AND WHERE ANATOMICALLY THEY START AND STOPApex of the lungs: 3-4cm above inner third of the claviclesBase: rests on diaphragm at about the 6th rib in the midclavicular lineLateral lung: extends from apex of axilla down to 7th or 8th ribPosterior:Apex: C7 or T1Base: T10On inspiration, lower lung border drops to T12Anterior:R and L lungs: Oblique fissure: crosses 5th rib in midaxillary line and terminates at the 6th rib in the midclavicular lineR Lung: horizontal fissure (divides right upper and middle lobes) extends from the 5th rib in the right midaxillary line to the 3rd intercostal space or 4th rib at the right sternal borderPosterior:Upper lobes: T1 to T3-4T3-4 down to Base: T10Lateral:Upper lobe: apex of the axilla down to the horizontal fissure at the 5th rib (horizontal fissure: 5th rib mid axillary line to 4th rib midsternal line)Right middle lobe: horizontal fissure down and forward to the 6th rib at the midclavicular lineRight lower lobe: continues from the 5th rib to the 8th rib in the midaxillary line (oblique fissure: 4th rib in the posterior axillary line to the 6th rib at the miclaviclar line)Left upper lobe: apex of axilla down to 5th rib at the midaxillary lineDiscuss abnormal shapes of chest (e.g. scoliosis, kyphosis) and their impact upon bodily systems (e.g. respiratory, cardiac) Normal: thorax elliptical w/ AP to transverse diameter 1:2 or 5:7; ribs downward slopingBarrel chest: equal AP to transverse diameter w/ ribs horizontal (associated with normal aging and COPD with hyperinflation of lungsPertus excavatum: markedly sunken sternum and adjacent cartilage (funnel breast)—depression begins at 2nd ICS, becoming depressed most at junction of xiphoid and body of sternum—more noticeable on inspiration (congenital, usually not symptomatic)Pertus carinatum: forward protrusion of sternum, ribs sloping back at either side and vertical depression along costochrondral junctions (pigeon breast)—minor deformity that requires no TxScoliosis: S-shaped curvature of thoracic and lumbar spine with vertebral rotation—mild deformities are asymptomatic—severe (>45? deviation) may reduce lung volume and pt at risk for impaired cardiopulmonary functionKyphosis: exaggerated posterior curvature of thoracic spine (humpback) that causes significant back pain and limited mobility—severe deformities impair cardiopulmonary functionIf neck muscles are strong, compensation occurs by hyperextension of the head to maintain level of visionAssociated with aging (dowager’s hump) of postmenopausal osteoporotic women; may be associated with physical fitness (inadequate)ABDOMEN (Ch. 21):Know anatomy and physiologyKnow order of physical examination and order of what is done in each section AND HOW IT IS DONEInspection:Contour: flat, scaphoid (caved in), rounded, protuberant; describes nutritional stateAbnormalBulges or massesHernia: protrusion of abdominal viscera through abnormal opening in muscle wallSymmetry: note any bulging, visible masses, or asymmetric shape by shining a light acrossUmbilicus: normally midline or inverted; no signs of discoloration, inflammation, or hernia; no redness or crustEverted with ascites or underlying massDeeply sunken with obesityEnlarged, everted with herniaBluish periumbilical color with intra-abdominal bleeding (Cullen sign)—rare Skin: smooth and even, homogenous color (good to judge pigment—protected from sun)Note scars: may give evidence of underlying adhesions and excess fibrous tissueRedness: localized inflammationAscites: skin glistening and taut; striaeStriae: purple-blue with Cushing’sVeins usually not seenProminent dilated veins occurs with portal HTN, cirrhosis, ascites, or venal caval obstruction; visible with malnutritionTurgor: good=healthy nutrition; poor=dehydration, accompanying GI diseasePulsation or movement: normal to see pulsations from aorta and respiratory movement (males); peristalsis in thin personsMarked aortic pulse with widened pulse pressure (HTN, aortic insufficiency, thyrotoxicosis; aortic aneurysm)Marked visible peristalsis, together with distention, indicates intestinal obstructionHair distribution: diamond shape in males and inverted triangle in femalesDemeanor (calm and relaxed or restless and constant turning (colicky pain of gasteroenteritis or bowel obstruction); absolute stillness occurs with pain of peritonitis; knees flexed, facial grimacing, and rapid uneven respirations indicate painAuscultate: (use diaphragm—high pithed)Normal: high pitched, gurgling, cascading sounds, occurring irregularly anywhere from 5-30/minBorborygmus: hyperactive stomach growling (normal)5min must go by if no sound is heard to declare absent bowel soundsHyperactive: high-pithed, rushing, tinkling soundHypoactive: follows abdominal surgery or inflammation (peritonitis)Vascular sounds:Bruits over aorta, renal arteries, iliac, and femoral arteries (esp in HTN)Normally no sound present (may have a normal bruit originating at celiac artery if <40)Systolic bruit is a pulsatile blowing sound and occurs with stenosis or occlusion of an arteryVenous hum and peritoneal friction rub are rarePercussion: (general tympany, liver span, and splenic dullness)General tympany:Over all 4 quads to determine prevailing amount of tympany and dullness (clockwise)Tympany predominates d/t air in intestines rising to surface while supineDullness occurs over distened bladder, adipose tissue, fluid, or massesHyperresonance is present with gaseous distentionLiver span:Map boundaries of liverHeight of liver in right midclaviular line by beginning in area of lung resonance until dullness (mark); percuss up from tympany of abdomen until dullness (normal distance between 2 marks is 6-12cm)10.5 for males; 7 for femalesSplenic dullness: percuss for dull note from the 9th to 11th ICS just behind the left midaxillary line (area of dullness not normally wider than 7cmDullness forward of the midaxillary line indicates splenic enlargement (mono, trauma, infection)Costoceterbral angle tenderness (indirect fist percussion causes tissues to vibrate instead of producing a sound)Assess kidneys: place hand over 12th rib at costovertebral angle on back and thump with fist of other hand—normally a thud with no painGas from AscitiesFluid wave test: fluid wave present with ascites; no change with gasShifting dullness: tympanic note over abdomen and dullness where there is fluid; then have person roll toward you shifting the fluid and percuss for dullness over tympanyPalpate (Light and deep)Liver: if palpated 1-2cm below right costal margin, it is enlarged; record number of cm and consistency (hard, nodular) and tendernessSpleen: not normally palpable (enlarged 2-3x normal size to be felt)—can rupture easily (don’t palpate)Palpate obliquely with right hand on the LUQ with fingers pointing toward left axilla and just inferior to rib margin (push deep and under left costal margin and ask person to take deep breath—should feel nothing firm)Enlarged with Mono, trauma, leukemias, and lymphomasKidneys: should feel nothingAorta: palpate by pinching b/t thumb and finger (normally 2.5-4cm wide, left of midline, and pulsates anteriorly)Rebound tenderness: Blumberg Sign—by pressing firmly and removing quickly, should elicit no pain with release of pressurePain=peritoneal inflammation (appendicitis)Inspiratory arrest: Murphy Sign—palpate under liver and ask pt to take a deep breathPain=inflammation of gallbladder (cholecystitis); pt will usually stop inspiring midwayKnow changes with aging process within these systemsOn inspection, you may note increased deposits of subq fat on the abdomen and hips because it is redistributed away from the extremities Abdominal musculature is thinner and has less tone than that of the younger adultBecause of thinner, softer abdominal wall, organs may be easier to palpate Liver is easier to palpateNormally you will feel the liver edge at or just below the costal marginDistended lungs and a depressed diaphragm – liver is palpated lower Kidneys are easier to palpate Changes in GI system:Salivation decreases causing dry mouth and decreased sense of tasteEsophageal emptying is delayed (supine feeding increases risk for aspiration)Gastric acid secretions decreases: may lead to pernicious anemia, iron deficiency anemia, and malabsorption of CaIncidence of gallstones increasesLiver size decreases by 25% b/t ages 20 & 70; liver function remains normal; drug metabolism impaired (age 65—33% blood flow decline)Constipation Describe pulsations—normal and abnormal in abdomen. Where may these pulsations be seen or feltUnder palpation aboveWhat are vascular sounds (arterial and venous) in abdomen—and location (p. 562)Arterial: bruit indicates turbulent blood flow (found in constricted, abnormally dilated, or tortuous vessels)Listen with bellConditions:Aortic aneurysm: murmur is harsh, systolic, or continuous and accentuated with systole (HTN)Renal artery stenosis: murmur is midline or toward flank, soft, low to medium pitchPartial occlusion of femoral arteriesVenous hum: rare; heard in periumbilical regionOriginate from inferior vena cava; medium pitch, continuous sound, pressure on bell may obliterate itMay have palpable thrillOccurs with portal HTN and cirrhotic liverDifferentiate light and deep palpationLight palpation: With the first four fingers close together, depress the skin about 1cmMake a gentle rotary motion, sliding the fingers and skin togetherLife the fingers (do not drag them) and move clockwise to the next location around the abdomenThe objective is not to search for organs but to form an overall impression of the skin surface and superficial musculature Save examination of any identified tender areas until last This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examDeep palpation:Uses same technique as light palpation but push down about 5-8cm (2-3in)Moving clockwise, explore the entire abdomen If a mass is noted—what are the eight assessment areas to be done to differentiate a normal palpable structure from enlarged organ (p. 547)LocationSizeShapeConsistency (soft, firm, hard)Surface (smooth, nodular)Mobility (including movement with respirations)PulsatilityTenderness Differentiate hyper/hypoactive bowel sounds—signs/symptoms and possible causation factorsHyperactive: loud, high-pitched, rushing, tinkling sounds that signal increased motilityLoud, gurgling sounds, “borborygmi” signal increased motilityOccur with early mechanical bowel obstruction (high-pitched), gastroenteritis, brisk diarrhea, laxative use, and subsiding paralytic ileusHypoactive: follow abdominal surgery or with inflammation of the peritoneumSignals decreased motility PeritonitisParalytic ileus as following abdominal surgery; late bowel obstruction; pneumonia Absent: no sounds in 5min in all four quadsWhy does auscultation precede percussion and palpationPercussion and palpation can increase peristalsis—gives false interpretation of bowel soundsKnow sing/symptoms of the following conditions: costovertebral angel tenderness, hepatomegaly, splenomegaly, pleural friction rub, aortic aneurysm, cirrhosis, gallbladder disease, peritoneal friction rub Peritoneal friction rub: rough, grating sound (two pieces of leather) indicates peritoneal inflammation; occurs over organs with a large surface area in contact with peritoneumLiver: friction rub over lower right rib cage, from abscess or metastatic tumorSpleen: friction rub over lower left rib cage in left anterior axillary line, from abscess, infection, or tumorCostovertebral angel tenderness: sharp pain occurring with inflammation of the kidney or paranephric areaHepatomegaly: Enlarged, smooth, and non-tender (fatty infiltration, portal obstruction or cirrhosis, high obstruction of IVC, and lymphocytic leukemia)Enlarged, smooth and tender (early HF, acute hepatitis, or hepatic abscess)Enlarged nodular liver: occurs with late portal cirrhosis, metastatic cancer, or tertiary syphilisSplenomegaly: enlarges down and to midline (not up d/t diaphragm); can extend down into left pelvisAcute infections (mono): moderately enlarged, soft, with rounded edgesChronic causes: firm or hard, with sharp edgesUsually not tender to palpation; tender if peritoneum is also inflamedAortic aneurysm: located below renal arteries (>95%) and extends to umbilicusFocal bulging >5cm; palpable ~80% of cases; feels like a pulsating mass in upper abd just to the left of midline; bruit heard; femoral pulses heard but decreasedGallbladder disease: felt behind liver border as a smooth and firm mass (like a sausage)Acute cholecystitisPainful to fist percussion and Murphy Sign present (inspiratory arrest)Nontender, enlarged gallbladder also feels like smooth sausage-like mass (occurs with stones—common bile duct obstruction)Differentiate solid and hollow viscera—and organ examples Solid: those that maintain a characteristic shapeLiver, pancreas, spleen, adrenal glands, kidneys, ovaries, and uterusHollow: stomach, gallbladder, SI, colon, and bladder (depends on contents of each)Know 4 quadrants of abdomen—anatomy in each quadrant RLQ:Cecum, appendix, right ovary and tube, right ureter, right spermatic cordRUQ:Liver, gallbladder, duodenum, head of pancreas, right kidney and adrenal gland, hepatic flexure, part of ascending and transverse colonLUQ: Stomach, spleen, left lobe of liver, body of pancreas, left kidney and adrenal gland, splenic flexure, part of transverse and descending colonLLQ: Part of descending colon, sigmoid colon, left ovary and tube, left ureter, left spermatic cordMidline:Aorta, uterus (if enlarged), bladder (if distended)Identify common cause of abdominal distentionObesity:Inspection: uniformly rounded; umbilicus sunken (adheres to peritoneum, and layers of fat are superficial to it)Auscultation: Normal bowel soundsPercussion: Tympany; scattered dullness over adipose tissuePalpation: Normal; may be hard to feel through thick abdominal wallAir or gas:Inspection: single round curveAuscultation: Depends on cause of gas (decreased or absent bowel sounds with ileus; hyperactive with early intestinal obstruction)Percussion: Tympany over large areasPalpation: May have muscle spasm of abdominal wallAscites:Inspection: Single curve; everted umbilicus; bulging flanks when supine; taut, glistening skin; recent weight gain; increase in abd girthAuscultation: Normal bowel sounds over intestines; diminished over ascitic fluidPercussion: Tympany at top where intestines float; dull over fluid; produces fluid wave and shifting dullnessPalpation: taut skin and increased intra-abd pressure limit palpationOvarian cyst (large):Inspection: curve in lower half of abd; midline; everted umbilicusAuscultation: normal bowel sounds over upper abd where intestines pushed superiorlyPercussion: top dull over fluid; intestines pushed superiorly; large cyst produces fluid wave and shifting dullnessPalpation: transmits aortic pulsations, whereas ascites does notPregnancy:Inspection: Single curve; umbilicus protruding; breasts engorgedAuscultation: fetal heart tones; bowel sounds diminishedPercussion: tympany over intestines, dull over enlarged uterusPalpation: fetal parts; fetal movementFeces:Inspection: localized distentionAuscultation: normal bowel soundsPercussion: tympany predominates; scattered dullness over fecal massPalpation: plastic-like or rope-like mass with feces in intestinesTumor:Inspection: localized distentionAuscultation: normal bowel soundsPercussion: dull over massif reaches up to skin surfacePalpation: defined borders; distinguish from enlarged organs or normally palpable structureDifferentiate: incisional hernia, epigastric hernia and umbilical herniaUmbilical: soft, skin-covered mass (protrusion of the omentum or intestine through a weakness or incomplete closure in the umbilical ring)Accentuated with increased intra-abd pressure (crying, coughing, vomiting, or straining)Adults: pregnancy, chronic ascites, or with chronic intrathoracic pressure (asthma, chronic bronchitis)Incisional: bulge new an old operative scar that may not show when a person is supine but is apparent when the person increases intra-abd pressure by a sit-up, standing, or by the Valsalva maneuverEpigastric: small, fatty nodule at the epigastrium in midline, through the linea alba (usually palpable when standing, not seen) ................
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