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Terms in this set (184)

•External Examination: - Inspect eyebrows for size, extension, and hair texture - Inspect orbital area for edema, puffiness, and sagging tissue below orbit • Eyelid inspection - Inspect closed lid for fasciculations and tremors - Check ability to close completely/open widely - Observe margin for flakiness, redness, and swelling - Look for eyelashes - Note eye opening • Ptosis - Note any eversion or inversion of lids
Eyelid palpation - Palpate for nodules - Palpate the eye itself through closed lids • Conjunctivae inspection - Usually unapparent, clear, and free of erythema - Inspect lower portion by pulling down lower lid - Upper lid is inspected only if foreign body is in the eye. - Look for redness/exudate - Look for pterygium • Abnormal growth of conjunctiva that extends over the cornea from the limbus

*Cornea -Examine clarity of the cornea by shining light on it. • Cornea is normally avascular; blood vessels should not be present. -Test sensitivity (cranial nerve V) by touching the cornea with a cotton wisp to elicit blink (cranial nerve VII). -Inspect for corneal arcus (arcus senilis). • Composed of lipids deposited in the periphery of the cornea
*Iris and pupil -Inspect iris for pattern, color, and shape -Test for direct/consensual light response -Test pupils for accommodation •The pupils should constrict when the eyes focus on the near object -Estimate pupil size and compare for equality
• Lens -Inspect for transparency/clarity • Sclera -Examine to ensure that it is white -Inspect for senile hyaline plaque • Lacrimal apparatus - Inspect lacrimal gland - Palpate lower orbital rim near inner canthus
• Chest pain
- Initial questions should be as broad as possible, such as, "Do you have any discomfort or unpleasant feelings in your chest?"
- Ask the patient to point to the location of the pain
- Use OLDCART • Onset and duration • Associated symptoms • Efforts to treat • Other medications • Recreational drugs (e.g., cocaine)
Chest pain - Aside from lung conditions, chest pain may arise from cardiac, vascular, gastrointestinal, musculoskeletal, or skin pathology; it is also commonly associated with anxiety
- Lung tissue itself has no pain fibers; pain in lung conditions usually arises from inflammation of the adjacent parietal pleura
- Other surrounding structures may also irritate the parietal pleura, causing pain

• Shortness of breath (Dyspnea)
- Non-painful but uncomfortable awareness of breathing that is inappropriate to the level of exertion
- Begin assessment with a broad question, such as, "Have you had any difficulty breathing?"
- Determine the severity of dyspnea based on the patient's daily activities

• Shortness of breath (Dyspnea) - Onset - Pattern - Position most comfortable, number of pillows used - Related to extent of exercise, certain activities, time of day, eating - Harder to inhale or exhale - Severity - Associated symptoms - Efforts to treat

• Wheezing
- Wheezes are musical respiratory sounds that may be audible to the patient and to others
- Airway obstruction form secretions, inflammation or foreign body
• Cough
- Reflex response to stimuli that irritate receptors in the larynx, trachea, or large bronchi
- May be cardiovascular in origin; left sided failure
• Cough Ask the patient to describe the volume of any sputum and its color, odor, and consistency - Onset - Nature of cough; dry or produces sputum, or phlegm - Sputum production: frequency and amount in 24 hours - Sputum characteristics; mucoid, foul smelling - Pattern - Severity - Associated symptoms - Efforts to treat

• Hemoptysis • Hemoptysis is the coughing up of blood from the lungs; it may vary from blood-streaked phlegm to frank blood - Ask the patient to describe the volume of blood produced as well as other sputum attributes - Try to confirm the source of the bleeding by history and examination before using the term "hemoptysis"; blood may also originate from the mouth, pharynx, or gastrointestinal tract
• General techniques - Examine the posterior thorax and lungs while the patient is sitting - Examine the anterior thorax and lungs with the patient supine - Compare one side of the thorax and lungs with the other, so the patient serves as his or her own control - Proceed in an orderly fashion: inspect, palpate, percuss, and auscultate

• Initial survey (Inspection) of respiration and the thorax - Observe the rate, rhythm, depth, and effort of breathing - Inspect for any signs of respiratory difficulty o Assess the patient's color o Listen to the patient's breathing o Inspect the patient's neck - Observe the shape of the chest
• Observe for peripheral clues may suggest pulmonary or cardiac difficulties: - Breath: odor - Skin, nails, and lips: cyanosis or pallor - Fingers: clubbing - Lips: pursing - Nostrils: flaring
• Examination of the posterior chest - Inspection o From a midline position behind the patient, note the shape of the chest and the way in which it moves

• Palpation of the thoracic muscles/skeleton - Pulsations - Tenderness - Bulges/depressions - Masses - Unusual movement/positions - Elasticity of rib cage - Immovability of sternum - Rigidity of thoracic spine • Position of the trachea (head & neck exam)

• Percuss chest -Anterior -Lateral -Posterior • Compare tones bilaterally
Examination of the posterior chest - Percussion o Perform from side to side to assess for asymmetry o Strike using the tip of your tapping finger o Use the lightest percussion that produces a clear note o Percussion helps establish whether the underlying tissues (5-7 cm deep) are air-filled, fluid-filled, or solid o Percussion notes Flatness, dullness, resonance, hyperresonance, tympany
• Percussion tone indicators for lungs -Resonance is normal. -Hyperresonance indicates hyperinflation. -Dullness indicates diminished air exchange

- Palpation o Assess any observed abnormalities and identify any tender areas
Feel for tactile fremitus, or palpable vibrations as the patient is speaking
o Chest expansion o Place thumbs at the level of the 10th rib with fingers loosely grasping and parallel to the lateral rib cage; watch the distance between the thumbs as they move apart during inspiration

• Auscultation with a stethoscope provides important clues to the condition of the lungs and pleura • All sounds can be characterized in the same manner as the percussion notes: - Intensity - Pitch - Quality - Duration
• Posterior chest - Auscultation o Auscultation of the lungs is the most important examination technique for assessing air flow through the tracheobronchial tree o Together with percussion, it also helps to assess the condition of the surrounding lungs and pleural space o Listen to the breath sounds with the diaphragm of a stethoscope after instructing the patient to breathe deeply through an open mouth o Use the pattern suggested for percussion, moving from one side to the other and comparing symmetric areas of the lungs o Listen to at least one full breath in each location
o Characteristics of normal breath sounds (pg. 303) Vesicular: soft and low pitched, low intensity; usually heard over most of both lungs Bronchial: louder and higher in pitch and intensity; usually heard over the manubrium Bronchovesicular: intermediate intensity and pitch; usually heard over the 1st and 2nd interspaces (major bronchi) Tracheal: very loud and high pitched, heard over trachea and neck

o Adventitious (added) sounds: Crackles (formerly called rales) • Abnormal respiratory sound heard more often during inspiration and characterized by discrete discontinuous sounds • Fine: high pitched, and relatively short in duration • Coarse: low pitched, and relatively longer in duration

o Adventitious (added) sounds: Rhonchi (sonorous wheezes) • Deeper, more rumbling, more pronounced during expiration, more likely to be prolonged and continuous, and less discrete than crackles • Caused by the passage of air through an airway obstructed by thick secretions, muscular spasm, new growth, or external pressure

o Adventitious (added) sounds: Wheezes (sibilant wheeze) • Continuous, high-pitched, musical sound (almost a whistle) heard during inspiration or expiration • Caused by a relatively high-velocity air flow through a narrowed or obstructed airway • May be caused by the bronchospasm of asthma (reactive airway disease) or acute or chronic bronchitis

• Examination of the posterior chest - Auscultation o Adventitious (added) sounds: Friction Rub • Occurs outside the respiratory tree • Dry, crackly, grating, low-pitched sound and is heard in both expiration and inspiration • Caused by inflamed, roughened surfaces rubbing together

o Adventitious (added) sounds: Mediastinal Crunch (Hammam Sign)) • Dry, crackly, grating, low-pitched sound and is heard in both expiration and inspiration • Caused by inflamed, roughened surfaces rubbing together • Occurs outside the respiratory tree
• Asthma (reactive airway disease) - Reversible small airway obstruction due to inflammation and hyperreactive airways • Atelectasis - Incomplete expansion of the lung at birth or the collapse of the lung parenchyma at any age • Bronchitis - Inflammation of the large airways

• Pleurisy - Inflammatory process involving the visceral and parietal pleura, which becomes edematous and fibrinous • Pleural effusion - Excessive nonpurulent fluid in the pleural space • Empyema - Purulent exudative fluid collected in the pleural space
• Lung abscess - Well-defined, circumscribed mass defined by inflammation, suppuration, and subsequent central necrosis • Pneumonia - Inflammatory response of the bronchioles and alveoli to an infective agent (bacterial, fungal, or viral)
• Influenza - Viral infection of the lung - Normally an upper respiratory infection, but due to alterations in the epithelial barrier, the infected host is more susceptible to secondary bacterial infections. • Tuberculosis - Chronic infectious disease that most often begins in the lung but may then have widespread manifestations
• Pneumothorax - Presence of air or gas in the pleural cavity • Hemothorax - Presence of blood in the pleural cavity • Lung cancer - Generally refers to bronchogenic carcinoma, a malignant tumor that evolves from bronchial epithelial structures
• Cor pulmonale - Acute or chronic condition involving right-sided heart failure • Pulmonary embolism - Embolic occlusion of pulmonary arteries - Relatively common condition - Difficult to diagnose

• Older Adults • Chronic obstructive pulmonary disease - COPD is a nonspecific designation that includes a group of respiratory problems in which cough, chronic and often excessive sputum production, and dyspnea are prominent features. - Not limited to older adults, smokers at greatest risk - Emphysema, bronchiectasis, and chronic bronchitis are the main conditions that are included in this group
• Emphysema - Condition in which the lungs lose elasticity and alveoli enlarge in a way that disrupts function • Bronchiectasis - Chronic dilation of the bronchi or bronchioles is caused by repeated pulmonary infections and bronchial obstruction. • Chronic bronchitis - Large airway inflammation, usually a result of chronic irritant exposure; more commonly, a problem for patients older than 40
• Inspection • Apical impulse - Should be visible at about the midclavicular line in the fifth left intercostal space • In some patients, it may be visible in the fourth left intercostal space • It should not be seen in more than one space if the heart is healthy • Obscured by obesity, large breasts, or muscularity

Palpating the Chest Wall
• Using the finger pads, palpate for heaves or lifts from abnormal ventricular movements: forceful cardiac contractions that cause a slight to vigorous movement of sternum and ribs. • Using the ball of the hand, palpate for thrills, or turbulence/ vibrations transmitted to the chest wall surface by a damaged heart valve • Examples: 1. Sustained lift at the Tricuspid area: RV 2. Systolic thrill at tricuspid area: VSD 3. Thrill at the Mitral area: MR or MS
• Palpation • Apical impulse - If it is more vigorous than expected, characterize it as a heave or lift. - Point of maximal impulse (PMI) • Point at which the apical impulse is most readily seen or felt - Thrill: a fine, palpable, rushing vibration, a palpable murmur • Carotid artery palpation
Assessing the Point of Maximal Impulse (PMI)
• Inspect the left anterior chest for a visible PMI • Using your finger pads, palpate at the apex for the PMI • The PMI may be: - Tapping — normal - Sustained — suggests LV hypertrophy from hypertension or aortic stenosis - Diffuse — suggests a dilated ventricle from congestive heart failure or cardiomyopathy • Locate the PMI by interspace and distance in centimeters from the midsternal line • Assess location, amplitude, duration, and diameter
Assessing the Carotid Pulse
• Keep the patient's head elevated to 30° • Place your index and middle fingers on the right then the left carotid arteries, and palpate the carotid upstroke • Never palpate right and left carotid arteries simultaneously • The upstroke may be: - Brisk - normal - Delayed - suggests aortic stenosis - Bounding - suggests aortic insufficiency • Listen with the stethoscope for any bruits - Bruits - turbulent blood flow outside the heart due to flow through narrowed or dilated vessel

* Of limited value in defining borders of heart or determining its size
Chest radiograph is far more useful in defining the heart borders

Listening to the Heart — Auscultation
• Listen in all 6 listening areas for S1 and S2 using the diaphragm of the stethoscope • Then listen at the apex with the bell • The diaphragm and the bell - The diaphragm is best for detecting high-pitched sounds like S1, S2, and also S4 and most murmurs - The bell is best for detecting low-pitched sounds like S3 and the rumble of mitral stenosis
• Auscultation • Assess overall rate and rhythm • Frequency • Intensity • Duration • Pathology
• Auscultation • Basic heart sounds - S1 or S2 most distinct - Splitting - S3 and S4 difficult to hear • Extra heart sounds - Gallops - Mitral snaps - Ejection clicks - Friction rubs
• Cardiac Disorders • Bacterial endocarditis - Bacterial infection of the endothelial layer of the heart and valves • Congestive heart failure - Heart fails to propel blood forward with its usual force, resulting in congestion in the pulmonary or systemic circulation • Myocardial infarction - Ischemic myocardial necrosis caused by abrupt decrease in coronary blood flow to a segment of the myocardium
• Conduction disturbances - Atrial flutter - Sinus bradycardia - Atrial fibrillation - Heart block - Atrial tachycardia - Ventricular tachycardia - Ventricular fibrillation

• Infants and Children Tetralogy of Fallot - Ventricular septal defect - Pulmonic stenosis - Dextroposition of the aorta - Right ventricular hypertrophy • Ventricular septal defect - Opening between the left and right ventricles • Patent ductus arteriosus - Failure of the ductus arteriosus to close after birth • Atrial septal defect - Congenital defect in the septum dividing the left and right atria • Acute rheumatic fever - Systemic connective tissue disease occurring after streptococcal pharyngitis or skin infection

• Older Adults • Atherosclerotic heart disease - Caused by deposition of cholesterol, other lipids, and by a complex inflammatory process • Mitral insufficiency/Regurgitation - Abnormal leaking of blood through the mitral valve, from left ventricle into left atrium • Angina - Pain caused by myocardial ischemia • Aortic sclerosis - Thickening and calcification of aortic valves
Splitting of heart sounds: Explanation of mechanism
What is splitting? What does it reflect? Instead of a single sound, you may hear two. During inspiration: ↑ capacitance pulm vascular bed → ejection of blood from vent delayed. P2 closes followed by A2 A2: louder. Heard throughout the precordium (pressure higher across aorta) P2: soft, heart best 2nd and 3rd LSB Not supposed to hear on expiration

Auscultating Murmurs

• Heart murmurs - Timing and duration: decide systolic or diastolic murmur - Pitch: high, medium or low - Intensity: 6 point scale grade I to VI - Pattern: crescendo-decreshendo - Quality: blowing, harsh, rumbling, musical - Location and radiation - Respiratory phase variations

Systolic and diastolic murmurs
• S1 Systole S2 diastole S1


• Systolic Murmurs: AS, MR, MVP • Diastolic murmurs: AI, MS

Systolic murmurs
AS: Ejection click Mis systolic murmur Creschendo decreschendo Peak aortic area Radiation to carotids MR: Pansystolic murmur. Location: apex. Radiation to axilla MVP: mid systolic click with late systolic murmur.

Diastolic murmurs
AI: listen at the LSB. Early diastolic murmur.

MS: opening snap (OS) OS followed by mid diastolic rumble.

Extra heart sounds
• Systolic click: EJ click of AS. Non ejection click of MVP

• Opening snap

• S3 and S4: heard best with the bell at the apex. L lateral decubitus position.

S3 or ventricular gallop
• Volume overload condition • Hear it in early diastole: rapid filling phase rushing to the LV • Tensing of chordae tendonae from pressure from LA --S3 • Normal children and young adults (heart can handle higher volume)

S4 (atrial gallop)
• Pressure overload problem • LV contracting againsts an increased pressure eg. HTN • With time ↑ stiffness • S4: heard when atrium contracts againsts a still LV • End of diastole right before the next cycle begins
Obtain a history of the redness and it's progression. Ask about other symptoms, such as eye itching, pain, swelling, discharge, or photophobia. Ask about exposures to chemical agents. Ask about systemic symptoms such as general malaise, skin rashes, and cold or allergy symptoms. Ask about family history of eye conditions. If the patient had eye trauma or abrasion, find out patient's tentanus status.
Determine patient's corrected visual acuity, then observe general characteristics of the redness, and finishing with a rapid assessment to rule out signs of trauma. Note if there is any photophobia and adjust the light to patient's comfort if possible. Assess the outer and appendage structures, looking for swelling, redness, discharge, or lesions. Next, focus on the eye itself, observing the cornea and conjunctiva for redness and noting the degree of pattern, and location of the redness. Identify any shadowing by passing oblique lighting over the anterior chamber. Assess the palpebral and tarsal conjunctiva beneath the lids; observe for foreign bodies or lesions. Assess the size, shape, and responsiveness of the pupils. If tolerated, perform a funduscopic examination. Depending on the history and examination of the eyes, it may be necessary to extend the assessment to the skin, ears, nose, throat and joints to assess for infections, allergy, or rheumatic disorders.
Diagnostic tests are helpful in assessing conjunctivitis. Studies can include viral and bacterial cultures of the conjunctiva or tests for atopy.
Corneal abrasion
Cornea can become scratched or abraded by a variety of situations, including trauma and foreign bodies. A common foreign body that causes corneal abrasions is a contact lens. Photophobia and significant tearing are common with abrasions. Fluorescein staining identifies an obvious break in the corneal surface with uptake of the stain. Diagnostic study is not indicated unless signs of infection are evident.
Chemical burns
Occurs from topical contact from many agents. Chemical burns make up the majority of ocular burns. Acidic burns do not penetrate the eye structure, alkali burns do cause penetrating injuries. The chemical should be identified as quickly as possible so that appropriate decontamination measures can be instituted immediately. Patient should be referred to an opthalmologist to determine the severity of injury.
Herpes Zoster
Herpes zoster is caused by the varicella-zoster virus and can affect the opthalmic branch of the cranial nerve V. Opthalmic involvement is often heralded by lesions on the tip of the nose. Lesions are usually preceded by a period of several days during which the patient experiences malaise and neuralgia along the affected nerve root. The pain is severe accompanied by systemic symptoms, including fever and fatigue. Photophobia may be present. Vision may be altered. Inspection of the cornea following fluorescein stain may reveal punctate or dentitic ulcerations. Patient should be referred to an opthalmologist. Specialist examination, including slit lamp to assess the degree of involvement. Virual cultures may be obtained.