PATIENT

ASSESSEMENT
 PHYSICAL EXAMINATION

I. General Appearance
II. Level of consciousness
III. Vital Signs
IV. Examination of Head and Neck
V. Examination of abdomen
VI. Examination of Extremities
VII. Examination of thorax
VIII.Examination of the heart
3
 I. GENERAL
APPEARANCE
⊹ Initial impression of the patient

⊹ Look for specific characteristics when looking at the patient

as a whole

⊹ General facial expression

⊹ Patient’s position may be useful in assessing the severity of

the problem.

⊹ Personal hygiene
 II. LEVEL OF
CONSCIOUSNESS
⊹ Also called evaluation of sensorium/alertness

⊹ If the patient appears conscious, the patient’s

orientation to time, place, person and
situation should be assessed
DELIRIOUS
 SLEEPY BUT AROUSES
EASILY

VERY SLEEPY – DIFFICULT TO AROUSE

RESPONDS MAINLY ON
STIMULI LIKE PAIN

IMAGINE A VEGETABLE
11
12
III. VITAL SIGNS
 Body temperature
 Pulse
 Respiratory rate
 Blood pressure
 Pain

14
TEMPERATURE
⊹ Normal body temperature for most people
is approximately 98.6° F (37° C), with a
normal range from 97.0° to 99.5° F and
daily variations of 1° to 2° F

⊹ The body temperature usually is lowest in

the early morning and highest in the late
afternoon.
15
⊹ Hypothalamus
⊹ Factors that influence body temperature:
● Age
● Diurnal variations
● Exercise
● Hormones
● Stress
● Illness
■ Hyperthermia- fever, viral/bacterial
infections, MI, malignancy, surgery and
trauma
■ Hypothermia – prolong exposure to cold.
16
17
18
 Routes of measuring body

“
temperature

⊹ Oral
⊹ Rectal (nearest to the core)
⊹ Axillary
⊹ Tympanic

19
⊹ The respiratory system also helps in the removal of excess heat
through ventilation.

⊹ When the inhaled gas is cooler than the body temperature, the
airways warm the gas to body temperature.

⊹ This warming and subsequent exhalation with each breath aids in

removing excess body heat.

⊹ When the inhaled gas is heated to near body temperature before

inhalation, this heat loss mechanism is not functional.

⊹ This most often occurs when the patient is intubated and receiving
mechanical ventilation with a heated humidifier in place.
20
Pulse rate
⊹ The left ventricle of the heart contracts with every beat,
forcing blood from the heart into the systemic arteries.

⊹ Amount of blood pumped from the heart with each

heartbeat is called stroke volume.

⊹ The force of the blood against the walls of arteries

generates a wave of pressure that is felt at various
points in the body as a Pulse
⊹ 60-100 beats per minute 21
22
23
⊹ The ability of the arteries to contract and
expand is called compliance.

⊹ When the compliance is reduced, the hear

must exert more pressure to pump blood
throughout the body.

24
Location of pulse points

“
⊹ Apical pulse
Differs by age
⊹ Peripheral pulse
⊹ Temporal
⊹ Common carotid
⊹ Brachial artery
⊹ Radial artery
⊹ Femoral artery
⊹ Popliteal artery
⊹ Posterior tibial
⊹ Dorsalis pedis
25
Factors that influence pulse rate
⊹ Age
⊹ Gender
⊹ Exercise
⊹ Stress
⊹ Fever
⊹ Hemorrhage
⊹ Medications
⊹ Position changes
26
27
“ LET’S TRY COUNTING
PULSE RATE”

28
Respiratory rate

29
30
31
BLOOD PRESSURE
⊹ It is the force exerted against the wall of the arteries as blood
moves through them.

⊹ Systolic pressure – peak force exerted by the major arteries

during contraction of the left ventricles.

⊹ Diastolic pressure – is the force of the major arteries after the

relaxation of the ventricles.

⊹ Pulse pressure – is the difference between systolic and diastolic

pressure. Normal pulse pressure is 30 -40mmHg.

⊹ 120/80mmHg 32
33
 FACTORS AFFECTING BP
“ ⊹ Age
⊹ Gender
⊹ Race
⊹ Obesity
⊹ Physical activity
⊹ Stress
⊹ Diurnal activity
⊹ Medications 34
35
Assessment of blood pressure
⊹ Prepare the patient
× Let the patient rest for 5 mins before taking the bp.
× 20 mins rest if the patient has been engaged in physical activity.
⊹ Equipment
× Blood pressure cuff
× Sphygmomanometer
× Stethoscope

36
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38
39
40
procedure
 Place the client in a comfortable position in a quiet
room.
 Confirm the bp cuff in an appropriate size for the
client’s arm.
 Remove any clothing from the client’s arm.
 Slightly flex the arm and hold it at the level of the heart
with the palm upward.
 Palpate the brachial pulse.
 Place the cuff on the arm with the lower border, 1 inch
above the antecubital area making sure that the cuff is
smooth and snug.
41
 One finger should fit between the cuff and the client’s arm. Be sure
that the center of the bladder is over the brachial artery. Many cuffs
have an arrow to indicate the center of the bladder.
 Palpate the radial pulse.
 Close the release valve on the pump.
 Inflate the cuff until the radial pulse is no longer palpable and note
the reading on the sphygmomanometer. This is the palpatory
systolic blood pressure.
 Place the diaphragm of the stethoscope over the brachial pulse.
 Pump the cuff until the sphygmomanometer registers 30mmHg
above the palpatory systolic blood pressure.

42
⊹ Release the valve on the cuff carefully so
that the pressure decrease at a rate of 2 to
3 mmHg per second.

⊹ Note: the manometer reading at each of

the Korotkoff phases. The first sound is
the systolic and the last sound is the
diastolic.

43
⊹ Deflate the cuff rapidly and completely.

⊹ Remove cuff from patient’s arm.

44
45
“ LET’S TRY OBTAINING
BLOOD PRESSURE”

46
PAIN
⊹ It is entirely subjective and personal
experience.

⊹ Acute or chronic

47
Pain history
⊹ Location
⊹ Intensity
⊹ Quality
⊹ Pattern
⊹ Precipitating factors
⊹ Actions to achieve pain relief
⊹ Impact on daily activities
⊹ Coping strategies
⊹ Emotional response

48
49
 IV. EXAMINATION
OF HEAD AND NECK
Head and Face
⊹ Patient’s facial expression

⊹ Nasal flaring is identified by observing the external nares flare

outward during inhalation.

⊹ Cyanosis

⊹ Pursed-lip breathing

⊹ Diaphoresis- excessive sweating (MI)

51
eyes
⊹ Pupillary reflex
⊹ Mydriasis
⊹ Miosis
⊹ Ptosis
⊹ Diplopia
⊹ Nystagmus

52
Neck
⊹ Tracheal position
⊹ JVP

53
Tracheal position
⊹ Affected side

⊹ Unaffected side

54
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56
⊹ https://www.youtube.com/watch?v=baxN
xWIWdK8

⊹ https://www.youtube.com/watch?v=AWx
bAg0E3E4

57
V. EXAMINATION OF
ABDOMEN
⊹ The abdomen should be inspected and palpated for
evidence of distention and tenderness.

⊹ Abdominal distention may cause impairment of

excursion of the diaphragm and contribute to
respiratory failure.

⊹ Distention may also inhibit the patient from coughing

and deep breathing, both of which are extremely
important in preventing respiratory complications in the
postoperative patient.

59
⊹ Hepatomegaly

⊹ Obesity

60
VI. EXAMINATION
OF EXTREMITIES
CLUBBING
⊹ is a significant manifestation of
cardiopulmonary disease.

⊹ commonly in patients with cyanotic

congenital heart disease, bronchogenic
carcinoma, COPD, cystic fibrosis, and
bronchiectasis

62
63
⊹ Clubbing is characterized by a painless
bulbous enlargement of the terminal
phalanges of the fingers and toes,
developing over many years.

⊹ The angle of the fingernail to the nail base

advances past 180 degrees, and the base
of the nail feels spongy.

⊹ The profile view of the digits allows

easier recognition of clubbing 64
cyanosis
⊹ a blue, gray, or purplish appearance of the skin,
common in patients with severe cardiopulmonary
disease.

⊹ The presence of cyanosis in the digits (peripheral

cyanosis or acrocyanosis) indicates that the blood
flow contains a reduction in oxygen-saturated
hemoglobin.

65
Capillary refill
⊹ is assessed by pressing firmly for a brief period on
the fingernail and identifying the speed at which the
blood flow returns.

⊹ When cardiac output is reduced and digital

perfusion is poor, capillary refill is slow, taking
several seconds to appear. In normal persons with
good cardiac output and digital perfusion, capillary
refill should take less than 3 seconds.
66
VI. EXAMINATION
OF THORAX
LUNG TOPOGRAPHY
⊹ Landmarks

68
Imaginary lines
⊹ Anterior
⬩ Midsternal line
● Left and right midclavicular line

⊹ Lateral chest
⬩ Midaxillary line
⬩ Anterior axillary
⬩ Posterior axillary

⊹ Posterior chest
⬩ Midspinal line
⬩ Left and right

69
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72
Thoracic cage landmarks
⊹ Anterior chest
× Suprasternal notch
× Angle of Louis
× Sternal angle
× Gladiolus
⬩ Second ribs
73
74
⊹ Posterior chest
× Spinous process
⬩ 7th vertebrae (C7)

75
76
Lung fissures
⊹ Interlobar fissures
⊹ Oblique fissures
⊹ Right lung
× Horizontal fissure

77
78
Tracheal bifurcation
⊹ On the anterior chest, the carina (tracheal
bifurcation) is located approximately beneath the
sternal angle (angle of Louis) and on the posterior
chest at approximately T4.

79
inspection
⊹ Visual examination

⊹ For inspection to be adequate, the room must be well lighted,

and the patient should be sitting upright.

⊹ If the patient is too ill to sit up, the clinician must roll the
patient carefully onto one side to examine the posterior chest.

⊹ Male patients should be stripped to the waist.

⊹ Female patients should be given some type of drape to prevent

possible embarrassment from exposure of their breasts.
80
Thoracic configuration
⊹ The normal adult thorax has an anteroposterior
diameter less than the transverse (side-to-side)
diameter.

⊹ The anteroposterior diameter normally increases

gradually with age and prematurely increases in
patients with COPD.

81
⊹ Barrel chest
× Emphysema
× Chronic hyperinflation

82
83
84
⊹ Pectus carinatum: outward sternal protrusion
anteriorly
⊹ Pectus excavatum: depression of part or all of the
sternum
⊹ Kyphosis: spinal deformity in which the spine has an
abnormal anteroposterior curvature
⊹ Scoliosis: spinal deformity in which the spine has a
lateral curvature.
⊹ Kyphoscoliosis: combination of kyphosis and scoliosis
⊹ Flail chest paradoxical motion of the affected rib cage

85
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⊹ https://www.youtube.com/watch?v=gtMc
EQSfje4

89
Breathing pattern and effort
⊹ The effort of breathing is minimum on inhalation
and passive on exhalation.

⊹ When ventilatory demands increase, these

accessory muscles become more active in assisting
the primary muscles of ventilation in the work of
breathing

90
⊹ Inward depression of the skin during inspiration is
known as retractions.

⊹ Retractions may be seen between ribs (intercostal),

below the ribs (subcostal), or above the clavicles
(supraclavicular)

91
⊹ https://www.youtube.com/watch?v=yBVk
_Bnyadc

92
⊹ The opposite movement of the skin during
exhalation is known as bulging.

⊹ Obesity and muscular chest walls prevent

retractions and bulging from occurring unless the
abnormality is severe.

93
⊹ Respiratory alternans consists of periods of
breathing using only the chest wall muscles
alternating ith periods of breathing entirely by the
diaphragm.

⊹ Abnormal movement of the lateral chest wall

during breathing in COPD patients with severe
hyperinflation is known as Hoover sign.

94
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96
97
⊹ https://www.youtube.com/watch?v=b_V9
2jwVUAo

⊹ https://
www.youtube.com/watch?v=ViGjOiPE2
mY

98
⊹ Central cyanosis
× is present when the patient’s trunk or oral mucosa is
cyanotic.
× This occurs when the lungs are not oxygenating the blood
adequately or when congenital heart disease causes
venous blood to be shunted into the arterial system
without passing through the lungs.
× Central cyanosis is an indication that tissue oxygenation
may not be adequate and that further investigation is
needed (e.g., arterial blood gas analysis).
× Cyanosis is apparent only when a significant amount of
reduced (deoxygenated) hemoglobin is present.

99
100
palpation
⊹ is the act of touching the chest wall in an
effort to evaluate underlying lung
structure and function.

⊹ Vocal fremitus, estimate thoracic

expansion, and assess the skin and
subcutaneous tissues of the chest.

101
Vocal fremitus
⊹ refers to the vibrations created by the vocal cords
during phonation.

⊹ These vibrations are transmitted down the

tracheobronchial tree and through the alveoli to
the chest wall.

⊹ When these vibrations are felt on the chest wall,

they are called tactile fremitus.
102
 “ninety-nine”

 The clinician can use the palmar aspect of

the fingers or the ulnar aspect of the hand.

103
⊹ https://www.youtube.com/watch?v=djyRr
UrIuw0

104
105
106
Thoracic expansion
⊹ Symmetrical
⊹ This expansion can be evaluated on the anterior and
posterior chest.

⊹ Anteriorly, the RT or other clinician’s hands are placed

over the anterolateral chest with the thumbs extended along
the costal margin toward the xiphoid process.
⊹ On the posterior chest, the hands are positioned over the
posterolateral chest with the thumbs meeting at
approximately T8.
107
⊹ The patient is instructed to exhale slowly and completely while
the clinician’s hands are positioned as described.

⊹ When the patient has exhaled maximally, the clinician gently

secures the tips of his or her fingers against the sides of the chest
and extends the thumbs toward the midline until the tip of each
thumb meets at the midline.

⊹ The patient is then instructed to take a full, deep breath. The

clinician should make note of the distance each thumb moves
from the midline.

⊹ Normally, each thumb moves an equal distance of approximately

3 to 5 cm.
108
⊹ Diseases that affect expansion of both lungs cause
a bilateral reduction in chest expansion
× Neuromuscular diseases
× COPD

109
⊹ Unilateral reduction
× Lobar consolidation
× Atelectasis
× Pleural effusion
× Pneumothorax.

110
111
⊹ https://www.youtube.com/watch?v=Ixm9
7rb3gxI

112
percussion
⊹ act of tapping on a surface in an effort to evaluate
the underlying structure.

⊹ Percussion of the chest wall produces a sound and

a vibration useful in the evaluation of the
underlying lung tissue.

⊹ The vibration created by percussion penetrates and

thus evaluates the lung to a depth of 5 to 7 cm
below the chest wall. 113
114
⊹ Hyperresonant
× A hollow-sounding pitch during
percussion.
⊹ Dull or Flat
× sound with characteristics just the
opposite of resonance.

115
⊹ Decreased percussion or resonance
× Increased density
× Consolidation (Pneumonia)
× Atelectasis
× Pleural effusion

116
⊹ Increased percussion or resonance
× Decreased density
× Hyperinflation (asthma, Emphysema,
pneumothorax)

117
⊹ https://www.youtube.com/watch?v=Lhe06
ZTBV_A

118
Diaphragmatic excurtion
⊹ The range of diaphragm movement may be estimated by
percussion and is assessed best on the posterior chest wall.

⊹ The clinician should work rapidly to prevent the patient from

becoming short of breath.

⊹ The normal diaphragmatic excursion during a deep breath is

approximately 5 to 7 cm.

⊹ The range of diaphragm movement is less than normal in

certain neuromuscular diseases and in patients with severe
pulmonary hyperinflation
119
auscultation
 is the process of listening for sounds produced in the
body.

 Auscultation over the thorax is performed to identify

normal or abnormal lung sounds.

 A stethoscope is used during auscultation for better

transmission of sounds to the clinician. The room must
be as quiet as possible whenever auscultation is
performed.
120
Stethoscope
⊹ The stethoscope includes four basic parts: a bell, a diaphragm,
tubing, and earpieces.

⊹ The bell detects a broad spectrum of sounds and is of particular value

in listening to low-pitched heart sounds. It is also valuable in
auscultation of the lungs in certain situations such as in the
emaciated patient whose rib protrusion restricts placement of the
diaphragm flat against the chest.

121
⊹ The bell piece should be pressed lightly against the chest
when the clinician is attempting to auscultate low-
frequency sounds. If the bell is pressed too firmly against
the chest wall, the skin will be stretched under the bell and
may act as a diaphragm, filtering out certain low-
frequency sounds.

⊹ The diaphragm piece is used most often in auscultation of

the lungs because most lung sounds are high frequency.

⊹ It is also useful in listening to high-frequency heart

sounds.

⊹ The diaphragm piece should be pressed firmly against the

chest so that external sounds are not heard. 122
⊹ Ideal tubing should be thick enough to exclude external
noises and should be approximately 19 inches in length,
with the total length of the stethoscope from the
binaurals to the diaphragm being a standard 27 inches.

⊹ Longer tubing may compromise transmission of lung

sounds, and shorter tubing often is inconvenient in
reaching the patient’s chest.

123
⊹ The stethoscope should be examined regularly for
cracks in the diaphragm, wax or dirt in the
earpieces, and other defects that may interfere with
the transmission of sound.

⊹ It should be wiped with isopropyl alcohol

regularly to prevent a buildup of microorganisms.

124
125
126
Four characteristics of breath
sounds
⊹ First, the pitch, either high or low pitch (vibration
frequency), is identified.

⊹ Second, the amplitude or intensity (loudness) is noted.

⊹ Third, the clinician listens for the distinctive

characteristics.

⊹ Fourth, the duration of inspiratory sound is compared

with that of expiration.
127
Normal Breath sounds
⊹ Lung sounds heard over the chest of the healthy person
are generated primarily by turbulent flow in the larger
airways.

⊹ Turbulent flow creates audible vibrations in the airways,

producing sounds that are transmitted through the lung
and the chest wall.

⊹ As the sound travels to the lung periphery and the chest

wall, it is altered by the normal lung.
128
⊹ Normal lung tissue acts as a low pass filter,
which means it preferentially passes low-
frequency sounds.

⊹ This filtering effect can be demonstrated easily

by listening over the periphery of the lung while
a subject speaks

⊹ The alteration of sounds that travel through the

lung is known as attenuation.

129
⊹ Attenuation accounts for the
characteristic differences between
tracheal and bronchovesicular breath
sounds heard directly over larger airways
and vesicular sounds heard over the
periphery of the lung.

⊹ Normal vesicular lung sounds are at least

partly produced locally in the underlying
lobe being auscultated.
130
⊹ Tracheal breath sounds
× the sound heard over the trachea has a loud, tubular
quality.
× Tracheal breath sounds are high-pitched sounds with
an expiratory component equal to or slightly longer
than the inspiratory component
× A slight variation to the tracheal breath sound is
heard around the upper half of the sternum on the
anterior chest and between the scapulae on the
posterior chest

131
⊹ Vesicular breath sounds
× Auscultating over the lung parenchyma of a healthy
person yields a soft, muffled sound.
× Normal breath sound, and is lower in pitch and intensity
(loudness) than the tracheal breath sound.
× Difficult to hear and is heard primarily during inhalation
with only a minimal exhalation component

132
⊹ Bronchovesicular breath sounds
× This is not as loud as the tracheal breath
sound

× slightly lower in pitch, and has equal

inspiratory and expiratory components

133
⊹ https://www.youtube.com/watch?v=JFW
MJGtmG5E

134
135
136
Tntensity of breath sounds
⊹ Harsh breath sounds
× Breath sounds are described as harsh when
the intensity increases.
× May have an expiratory component equal to
the inspiratory component and are described
as bronchial breath sounds in such cases.

137
Diminished breath sounds
⊹ occur when the sound intensity at the site of generation (larger airways)
is reduced or when the sound transmission properties of the lung or
chest wall are reduced.

⊹ The intensity of sound created by turbulent flow through the bronchi is

reduced with shallow or slow breathing patterns (e.g., major sedation).

⊹ Obstructed airways (e.g., mucous plugs) and hyperinflated lung tissue

(e.g., emphysema) increase attenuation of breath sounds through the
lungs.

⊹ Air (pneumothorax) or fluid (e.g., pleural effusion) in the pleural space

and obesity reduce the transmission of breath sounds through the chest
wall.
138
⊹ https://www.youtube.com/watch?v=9yUv
16icC_A

139
Abnormal bronchial breath
sounds
⊹ Bronchial breath sounds may replace the normal
vesicular sound when the lung increases in density, as
occurs in pneumonia and certain types of atelectasis.

⊹ When the normal air-filled lung becomes consolidated,

the attenuation of sound is reduced, and similar sounds
are heard over large upper airways and the consolidated
lung

140
141
Adventitious breath sounds
⊹ Abnormal sounds superimposed on the normal breath
sounds or sounds not normally heard in the particular
area of auscultation

⊹ refers to sounds that are added sounds or extra sounds

produced within a normal sound, or heard in a place
within the lung where that particular sound is not
normally heard, such as tracheal or bronchial breath
sounds heard over lung parenchyma

⊹ Continuous and discontinuous 142

Continuous breath sounds
⊹ defined as those having a duration longer than 25
msec.

⊹ This definition is derived from recording and

spectral analysis of lung sounds.

⊹ Clinicians are not expected to time the lung

sounds.

143
⊹ Wheezing
⊹ Rhonchi
⊹ Stridor

144
⊹ Rales
× is an outdated term that had a long, evolving
history and in the past was used to describe
discontinuous abnormal lung sounds.
× Like the term rales, the term rhonchi has a
confusing history and has been applied to more
than one type of abnormal lung sound by
various health care professionals.
× Crackles be used to describe discontinuous,
abnormal lung sounds, and the term rhonchi
be used to describe low-pitched, continuous,
abnormal lung sounds
145
⊹ Rhonchi
× Low-pitched “coarse” crackles (a
crackling sound) that are continuous

146
2
⊹ https://www.youtube.com/watch?v=CSpJ
hkIVez8

147
148
⊹ Wheezing
× used to describe the musical sounds heard from
the chest of the patient with intrathoracic airway
obstruction (e.g., asthma).
× Wheezes are classified as continuous sounds and
are easily recognized inmost cases.
× Are generated by the vibration of the wall of a
narrowed or compressed airway as air passes
through at high velocity.
× The diameter of an airway may be reduced by
bronchospasm, mucosal edema, increased mucus
production, or foreign object obstruction

149
150
⊹ https://www.youtube.com/watch?v=795u
Tkubs-M

151
⊹ Polyphonic wheezing
× Having several different musical notes.
× is limited to exhalation, and its many
different musical notes begin and end
simultaneously, indicating that multiple
airways are obstructed, as in asthma

152
⊹ https://www.youtube.com/watch?v=zU1w
MHeUfYQ

153
⊹ Monophonic wheezes
× may occur in one or more than one bronchus, with each
one indicating obstruction of a bronchus.
× When multiple monophonic wheezes are present, the
multiple notes often begin and end at different times;
therefore, these single-note wheeze sounds may overlap
wall.
× A single monophonic wheeze indicates obstruction of a
single airway.

154
× This may be present in the patient with an airway
tumor that is partially obstructing a major airway
or with aspiration of a foreign object.
× The clinician who hears a monophonic wheeze
over the patient’s chest should also auscultate over
the patient’s neck.

× If the wheeze is heard loudest over the neck, the

upper airway is the source of the sound.
155
⊹ https://www.youtube.com/watch?v=iX-Re
jkSUkk

156
⊹ Stridor
× primarily over the larynx and trachea during
inhalation when upper airway obstruction is present.
× This is a loud, high-pitched sound that often may be
heard without the aid of a stethoscope
× Produced by mechanisms similar to those of
wheezing.

157
× Rapid airflow through a narrow site of the
upper airway causes the lateral walls to vibrate
and produce a high-pitched sound often heard
without a stethoscope.
× The diameter of the upper airway is most often
narrowed because of infection, as in croup or
epiglottitis, or with inflammation after
extubation.

158
× Most often heard during inhalation because the
upper airway tends to narrow with significant
inspiratory efforts.
× It may also be heard during inhalation and
exhalation when the upper airway obstruction
is severe and fixed (airway opening does not
vary with breathing).
× This is seen in patients with laryngeal tumor

159
⊹ https://www.youtube.com/watch?v=vDdJ
o0RPKa8

160
Discontinuous breath sounds
⊹ are characteristically intermittent,
crackling, or bubbling sounds of short
duration.

161
162
Crackles
× when air moves through excessive fluid or
secretions in the airways, when collapsed
airways pop open during inspiration.
× Often are produced by the movement of
excessive secretions or fluid in the airways as
air passes through.
× Fine, course, early inspiratory, late
inspiratory

163
⊹ Course crackles
× Heard during inspiration and
expiration.
× They often clear if the patient coughs,
and they may be associated with
rhonchial fremitus

164
⊹ Early inspiratory crackles
× are usually few in number but may be loud or
faint.
× They often are transmitted to the mouth and
are not silenced by a cough or change in
position.
× They occur most often in patients with COPD,
as in chronic bronchitis, and emphysema, and
may indicate that a more severe airway
obstruction is present.
165
⊹ Late inspiratory crackles or fine crackles

× Crackles produced by the sudden opening of peripheral

airways usually occur late in the inspiratory phase.
× They are more common in the dependent regions of the
lungs, where the gravitational stress predisposes the
peripheral airways to collapse during exhalation.
× They are often identified in several consecutive respiratory
cycles, producing a recurrent rhythm.
× They may clear with changes in posture or if the patient
performs several deep inspiratory maneuvers.

166
× Coughing or maximal exhalation by the patient
may produce the reappearance of late inspiratory
crackles.
× Patients with respiratory disorders, such as
atelectasis, pneumonia, pulmonary edema, and
fibrosis, that reduce lung volume (restrictive
disorders) are most likely to have the late
inspiratory type of crackles

167
168
169
⊹ https://www.youtube.com/watch?v=z2Ra9
UxndI0

⊹ https://www.youtube.com/watch?v=8xUv
OWPJkWY

170
171
Pleural friction rub
⊹ is a creaking or grating type of sound that occurs
when the inflamed pleural membranes (pleurisy)
rub together.

⊹ It may be heard only during inhalation but often is

identified during both phases of breathing, with
the intensity of sound increasing during deep
breaths

172
⊹ Pleural rubs are rarely encountered in the clinical
setting and for this reason often are not identified
correctly when present.

⊹ Pleural rubs may be heard in patients with

pneumonia, pulmonary fibrosis, or pulmonary
embolism, or after thoracic surgery.

173
⊹ https://www.youtube.com/watch?v=zm0ja
BHmm10

174
Overall breath sounds
⊹ https://www.youtube.com/watch?v=KRtA
qeEGq2Q

175
Voice sounds
⊹ If inspection, palpation, percussion, or auscultation of
the patient’s chest suggests any respiratory abnormality,
vocal resonance may be useful.

⊹ Vocal resonance is produced by the same mechanism as

vocal fremitus

176
⊹ The vibrations created by the vocal cords during
phonation travel down the tracheobronchial tree and
through the peripheral lung units to the chest wall. The
patient is instructed to repeat the words “one, two,
three” or “ninetynine” while the clinician listens over
the chest wall with the aid of a stethoscope, comparing
side with side

177
⊹ Bronchophony occurs as a result of an increase in
lung tissue density, as in the consolidation of
pneumonia, and is the result of the better
transmission of vocal vibrations through
consolidation.

⊹ Is easier to detect when it is unilateral and is often

associated with bronchial breath sounds, dull
percussion note, and increased vocal fremitus.

178
⊹ Egophony is when the spoken voice sounds
increase in intensity through the chest wall and the
quality sounds nasal or bleating.

⊹ This is assessed by the clinician when the patient

is asked to say “e-e-e” but the sound is heard as
“a-a-a” through the stethoscope.

⊹ The area where it is heard may indicate a

compressed lung above a pleural effusion.

179
⊹ Whispering pectoriloquy is a technique to assess a
patient for lung consolidation.

⊹ Whispering of the words “one, two, three” by the

patient creates high-frequency vibrations that are
selectively filtered by normal lung tissue.

⊹ Normally, whispers are heard as muffled, low-

pitched sounds through the stethoscope.

⊹ If the clinician hears high-pitched sounds, this is

evidence that consolidation is present in the lung.
180
⊹ https://www.youtube.com/watch?v=P_Io
DaDzPz0

181
EXAMINATION OF
PRECORDIUNM
⊹ Include inspection, palpation, and
auscultation.

183
184
INSPECTION AND
PALPATION
⊹ to identify any normal or abnormal pulsations.

⊹ Pulsations on the precordium are affected by the

thickness of the chest wall and the quality of the tissue
through which the vibrations must travel.

185
⊹ The normal apical impulse is produced by
the thrust of the contracting left ventricle
and usually is identified near the
midclavicular line in the fifth intercostal
space.
⊹ This systolic thrust may be felt and
visualized in many healthy persons; it
may be called the point of maximal
impulse (PMI).

186
⊹ https://www.youtube.com/watch?v=hKY
mbwKZRss

187
⊹ Right ventricular hypertrophy, a common
manifestation of chronic lung disease, often
produces a systolic thrust (heave) that is felt and
may be visualized near the lower left sternal
border.

⊹ The palmar aspect of the clinician’s right hand is

placed over the lower left sternal border for
identification.

⊹ Right ventricular hypertrophy may be the result of

chronic hypoxemia, pulmonary valve disease, or
pulmonary hypertension.
188
⊹ The PMI may shift to the left or right with shifts in the
mediastinum.

⊹ Pneumothorax or lobar collapse often shifts the

mediastinum, resulting in a shift of the PMI toward the
lobar collapse but usually away from the pneumothorax.

⊹ Patients with emphysema and low, flat diaphragms may

have the PMI located in the epigastric area.

⊹ The second left intercostal space near the sternal border is

called the pulmonic area and is palpated in an effort to
identify accentuated pulmonary valve closure.
⊹ Strong vibrations may be felt in this area with pulmonary
hypertension 189
190
AUSCULTATION OF
HEART
⊹ Normal heart sounds are created primarily by the
closure of the heart valves.

⊹ The first normal heart sound is S1, produced by

the sudden closure of the mitral and tricuspid
valves (often called the atrioventricular [AV]
valves), which happens virtually simultaneously
during contraction of the ventricles (systole)

191
⊹ The second normal heart sound is S2.

⊹ When systole ends, the ventricles relax and the pulmonic

and aortic (semilunar) valves close, which signals the
onset of diastole and creates the second heart sound (S2).

⊹ Because the left side of the heart has a significantly

higher pressure created during systole, closure of the
mitral valve is louder and contributes more to the S1
sound than the closure of the tricuspid valve in the
healthy person.

192
⊹ For the same reason, closure of the aortic valve
usually contributes more to the production of S2.

⊹ Both S1 and S2 heart sounds are normally heard in

all populations.

⊹ The S3 and S4 heart sounds are only normal in

small children and may indicate a murmur in
adults

193
⊹ A split in the S1 sound is heard when the tricuspid
valve closure is delayed, and the sounds of the
mitral and tricuspid valve are heard separately.

⊹ This significant splitting of S1 usually indicates

heart disease.

⊹ Defects in the electrical conduction system of the

heart, such as bundle branch block, cause the two
ventricles to lack synchrony during systole, causing
a splitting of S1

194
⊹ Splitting of S2 occurs when the semilunar valves
(pulmonic
⊹ and aortic) do not close simultaneously.

⊹ A physiologically normal, narrow splitting of S2 is due to

the effects of spontaneous breathing on blood flow into
the heart.

⊹ During inhalation, there is a decrease in intrathoracic

pressure, increasing venous return to the right side of the
heart, which further delays pulmonic valve closure. The
splitting of S2 decreases or disappears on exhalation.

195
⊹ Wide splitting of the second heart sound
(significantly delayed closure of the pulmonic
valve after the aortic valve) is usually a sign of
disease and is seen with pulmonary hypertension,
right bundle branch block, pulmonary embolism,
and right-sided heart failure.

196
⊹ A third heart sound (S3) may be identified early in
diastole.

⊹ S3 is thought to be produced by rapid ventricular filling

immediately after systole.

⊹ The rapid distention of the ventricles causes the walls of

the ventricles to vibrate briefly and produce a sound of
low intensity and pitch.

⊹ It is best heard over the apex with the bell of the

stethoscope.

⊹ It is normal in young healthy children and is called

physiologic S3 in this situation.
197
⊹ https://www.youtube.com/watch?v=dBwr
2GZCmQM

198
199
Gallop rhythm
⊹ is an abnormal condition in which a third (S3) or fourth
(S4) heart sound is present.

⊹ The spacing of the heart sounds results in a unique

sequence of sounds that resembles the gallop of a horse.

⊹ A gallop rhythm suggests that the left or right ventricle

is being overdistended during diastole.

200
⊹ When an S3 or S4 is present and originates in the
right ventricle, it is best heard at the left sternal
border near the apex.

⊹ When the S3 or S4 originates in the left ventricle,

it is best heard at the midclavicular line over the
apex of the heart.

201
⊹ Pulmonary hypertension increases intensity of S2
as a result of more forceful closure of the pulmonic
valve; this is called an increased or loud P2.

⊹ A loud P2 is a common finding in patients with

pulmonary hypertension, cor pulmonale, and
pulmonary embolism because high pulmonary
artery pressures cause the pulmonic valve to close
with more force.

⊹ An increased P2 is identified best over the

pulmonic area of the chest
202
⊹ Cardiac murmurs are identified whenever the heart valves are
incompetent (incomplete closure) or stenotic (narrowed).

⊹ Murmurs usually are classified as either systolic or diastolic.

⊹ Systolic murmurs occur during systole and are heard following

S1.
⊹ These murmurs are produced by an incompetent AV valve as in
mitral valve regurgitation or a stenotic semilunar valve as in
aortic valve stenosis.
⊹ An incompetent mitral valve allows a backflow of blood into
the left atrium, usually producing a high-pitched whooshing
noise simultaneously with S1.

⊹ A stenotic aortic valve produces a similar sound because a

narrowed valve creates an obstruction of blood flow out of the
ventricle during systole. 203
⊹ Diastolic murmurs occur during diastole and are
heard following S2.
⊹ These murmurs are created by either an incompetent
semilunar valve, as in aortic regurgitation, or a
stenotic AV valve, as in mitral stenosis. In aortic
regurgitation, an incompetent aortic valve allows a
backflow (reflux) of blood from the aorta into the
left ventricle simultaneously with or immediately
after S2.

⊹ A stenotic mitral valve obstructs blood flow from

the left atrium into the left ventricle creating a
turbulent murmur sound
204
⊹ A murmur may also be created by rapid blood
flow across normal valves.

⊹ In summary, murmurs are created by a backflow

of blood through an incompetent valve, forward
flow through a stenotic valve, and rapid flow
through a normal valve

205
⊹ The diaphragm of the stethoscope is most useful for higher-
frequency sounds such as S1, S2, and systolic murmurs.

⊹ The bell side of the stethoscope is best used for low-

frequency sounds such as gallops (S3 and S4) and diastolic
murmurs.

⊹ The heart sounds may be easier to identify if the patient

leans forward or lies on the left side because anatomically
this moves the heart closer to the chest wall.

⊹ When the peripheral pulses are difficult to identify,

auscultation over the precordium may be an easier method
of assessing the heart rate.
206
⊹ https://www.youtube.com/watch?v=dBwr
2GZCmQM

207