Download Physical Exam

Physical Examination
(continued)
Sean Ragain MD
Quick Review
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So far, you’ve covered a lot of ground. Let’s
look at what you’ve already seen and heard.
Inspection, palpation, percussion, auscultation
(not necessarily in this order).
Exam is modified per patient
Only time and practice can lead to
proficiency!
Review
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Head exam (HEENT and sometimes N-neck)
Lung topography – imaginary lines,
landmarks, fissures, trachea, diaphragm, lung
borders
Thoracic Inspection - i.e. barrel chest, pectus
excavatum/carinatum, breathing patterns.
Thoracic Palpation – fremitus, crepitus,
fractures.
Review
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Thoracic Percussion – consolidation?
Atelectasis? Increased or decreased
resonance?
What’s Next???
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Thoracic Auscultation! Or, auscultation of the lungs.
Mostly done with a stethoscope of course, but you
will often get a lot of info just from listening to the
person breathe with your “naked” ears. Do your best
to achieve quiet in the room so you can hear!
Diaphragm vs. bell of stethoscope.
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Mostly, we use the diaphragm, but the bell is particularly
good at picking up low frequency sounds, such as certain
heart murmurs/valve disorders.
Auscultation
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Some sources say to work your way down,
but your book says work your way up. Most
important: Do side to side comparisons as you
move throughout the lung fields.
Stethoscope
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What is the difference between the bell and
diaphragm?
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Diaphragm sits flush against the skin, and therefore filters
a lot of low frequency sounds out.
Most lung sounds are high frequency, so we usually
employ the diaphragm.
The bell can be an adjunct to the diaphragm. Also, it may
be helpful in the emaciated patient.
Don’t press too hard on the bell, this will essentially make
it like the diaphragm!
Technique
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Quiet Room
As little dress as necessary (and appropriate)
If you must, a thin t-shirt or a hospital gown is
ok (but not preferrable) to listen through.
At least one full respiratory cycle at each
point of auscultation.
Breath Sounds (table 5-2)
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Tracheal breath sounds – Not surprisingly, these
should normally be heard over the trachea in the
midline of the neck, superior to the sternal notch.
They are loud, high pitched, and are equal in length
during inspiration and expiration.
Bronchovesicular breath sounds – quieter than
tracheal sounds, but otherwise quite similar. Heard
around the upper half of the sternum, and between
the scapulae on the back. If these sounds are heard
coming from large parts of the lung, there may be
pathology.
Breath Sounds
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Vesicular – soft, muffled sound that is lower
in pitch and intensity than tracheal or
bronchovesicular breath sounds. Has a longer
inspiratory than expiratory component. This
is what normal lungs should sound like.
Breath sound intensity
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If markedly increased in intensity, they are
said to be harsh, the opposite would be
described as diminished or even absent.
Adventitious breath sounds
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Fortunately, not too many of these to
remember, because most diseases present with
common adventitious sounds.
Can be classified as continuous or
discontinuous.
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In general, continuous adventitious sounds, are
wheezes, and discontinuous ones are crackles.
Adventitious breath sounds
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So we have…
Crackles
Wheezes
Rales
Rhonchi
Stridor
But the terms rales and rhonchi are falling into
disuse (to some degree).
Let’s listen to some!
Mechanisms Responsible (intro)
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Normal breath sounds are created by turbulent flow in the
airways
Bronchial breath sounds heard in the lung periphery may
result from consolidation.
Diminished sounds may result from emphysema, collapse,
obesity etc.
Crackles are caused by the sudden opening of collapsed
airways, or by fluid in the airways.
Wheezes are produced by the vibration of narrowed airways
as air passes through (like a reed instrument).
Stridor is often caused by upper airway obstruction.
Examination of the Precordium
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The precordium is the surface of the chest
wall overlying the heart.
It is examined to assess the condition of the
heart. Also, we examine the precordium
through the EKG.
Review of Heart Topography
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The base of the heart lies directly beneath the
middle portion of the sternum
The apex points downward and to the left,
extending to the midclavicular line near the
5th ICS.
Inspection and Palpation of the
Precordium
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Mostly in inspection, you are looking for
chest wall deformities, and whether or not you
see heaves. What are heaves?
Also, you may try to find the PMI, especially
with the initial exam. This may tell you if a
person’s heart is enlarged.
Auscultation of heart sounds
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The first heart sound (S1) is created by closure of the
AV valves. Which ones are those?
The second heart sound (S2) is created by closure of
the aortic and pulmonary semilunar valves.
A split S1 or S2 may occur if the opposing valves
close at different times.
Significantly split S1 usually indicates a problem
(i.e. bundle branch block).
Split S2 can be heard with deep inspiration, but this
should return to non-split with exhalation.
Adventitious heart sounds
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There are also times when you will hear an S3
or S4. This is often found in heart failure
other reasons for the heart to be stiff.
A loud S2 in the “P” area may indicate
pulmonary hypertension.
Areas for good auscultation
Murmurs
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Caused by incompetent or stenotic valves
(usually).
Systolic Murmurs are heard when the
semilunar valves are stenotic or when the AV
valves are incompetent.
Diastolic Murmurs are heard when the AV
valves are stenotic or when the semilunar
valves are incompetent.
Neurologic Examination
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The neurological exam is done by the
physician when brain or spinal cord injury is
suspected.
RTs need to be familiar with the results of this
exam because it has implications for the
pulmonary system
Neuro Exam
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Review
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The CNS is made up of the brain and spinal cord
The brain stem is the most important part of the CNS
regarding breathing. It is where breathing is regulated and
controlled.
The spinal cord connects the brain to the peripheral body
parts for sensory and motor function
The PNS is made up of the cranial nerves and 31
spinal cord nerves
Assessment of the CNS
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General level of consciousness
A coma is present when a person cannot be
awakened from a sleeplike state.
The Glasgow Coma Scale (GCS) is often used to
document the level of neurological impairment.
The patient’s response to pain is also used to assess
the CNS.
The patient’s breating pattern often provides clues
about the level of brain stem function. CheyneStokes breathing is a common finding with brain
stem injury.
GCS
Cheyne-Stokes Breathing
Neuro Assessment
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PNS
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A variety of motor and sensory tests are done.
Reflexes
Strength
Proprioception
Touch, pinprick, vibration.
Cranial Nerves
Cranial Nerves and the Exam
Reflexes
Abdominal Exam
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The proper order of the abdominal exam is
more important than the order of the
respiratory exam.
Inspection, auscultation, palpation,
percussion.
Why?
Anatomy of the Abdomen
Abdomen
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An enlarged liver is known as hepatomegaly.
Right heart failure can cause this.
Severe abdominal distension can impede
movement of diaphragm. Such as severe
ascites, or bowel obstruction.
Examination of the Extremities
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Clubbing
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Often seen in patients with chronic
cardiopulmonary disease. Cyanotic heart disease,
COPD, and lung cancer may also lead to this.
Cyanosis
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Peripheral cyanosis is a sign of circulatory
disease.
Pedal Edema
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May be a sign of chronic lung disease and
right heart failure.
But often occurs in healthy older individuals,
and may come and go in healthy younger
individuals.
Capillary Refill
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Will be delayed if cardiac output is poor.
It is tested simply by compressing capillary
bed in an extremity, and seeing how long it
takes to “pink up”.
Peripheral Skin Temperature
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Cool skin is often poorly perfused skin.
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THE END