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PATIENT
ASSESSMENT
TABLE OF CONTENTS
(click
on the links below to view more details)
Learning
Objectives
Introduction
Evaluation
Patient
Interview
Medical
History Taking
Observation
The
Actual Physical Examination of the Patient
Special
Tests
Chest
X-ray Analysis
Sputum
Analysis
Microbiologic
Tests
Carbon
Dioxide Challenge Test
Testing
Patients Pulmonary Function (PFTs)
Arterial
Blood Gas Analysis (ABGs)
Ventilation/Perfusion
Lung Scanning
Interpreting
Laboratory Test Data
Tuberculosis
Primer
on Basic Concepts of ECG
Glossary
Post
Test

Learning Objectives
Upon
successful completion of this course, and given an open-book,
multiple-choice exam, you will be able to correctly answer
a minimum of 90% of the test items requiring you to:
- Identify
and demonstrate methods for conducting a physical assessment
of the patient,
- List
and discuss the important elements of interviewing a patient
and taking a medical history, including how to document
the information.
- Identify
and explain the purposes of chest roentgenography and key
laboratory tests employed in patient assessment, with an
emphasis on pulmonary tests
- Discuss
the procedures and purposes of sputum examinations
- Identify
and explain the techniques for pulmonary function testing
- Identify
and explain the purposes of laboratory tests used in patient
assessment

Introduction
Physicians
have traditionally had sole responsibility for assessing patients,
making a diagnosis, and prescribing protocols for care. In
the past, the gathering of patient data, subsequent interpretation
of that data, and prescription of therapies was the sole domain
of physicians.
Other
allied health professionals (nurses, physician assistants,
and respiratory care practitioners) have historically had
the option of communicating with attending physicians regarding
the patients prescribed therapeutic regimen. However,
lack of confidence and fear of having their input rejected
(and possibly disrespected) has inclined many allied health
professionals to remain silent. This resulted in the prescription
and performance of numerous costly and unnecessary procedures.
Progress
in the science and technologies relating to patient assessment
has placed increasing demands on non-physician health care
professionals (from RNs and LVNs to Respiratory Care Practitioners).
The integration of assessment with treatment is a necessary
outcome of the growing complexity of the roles and functions
being assumed by these non-physician caregivers.
It
is no longer acceptable to initiate or alter therapy or treatments
without careful consideration of the underlying disorder and
its clinical manifestations. Since it is not possible for
physicians to be experts in all the fields in which their
allied health companions practice, decisions regarding when
to begin, change, or end treatments or therapies must be based
on tangible clinical evidence, with input from all caregivers.
Although the physician has primary responsibility for these
decisions (not unlike the captain of the ship
concept), other caregivers must participate in the clinical
decision-making process. In order to fulfill this role effectively,
health care proffesionals must assume responsibility for gathering
and interpreting relevant patient data.
These
non-physician caregivers have historically had the option
of communicating with attending physicians regarding the patients
prescribed therapeutic regimen. Lack of confidence and sometimes
even fear of having their input rejected (and possibly disrespected)
has inclined many caregivers to remain silent. This has resulted
in the prescription and performance of numerous costly and
unnecessary procedures (especially in the area of patients
respiratory care).
Authors
Note:
In
this course, the terms nurses, RCPs, and caregivers are used
interchangeably because all the terms refer to non-physician
health care professionals who are trusted licensed professionals
and whose sole purpose is to provide health care. In addition,
there are a wide variety of examinations and techniques included.
While some of you may not be concerned with or ever perform
all of these, we have tried to make the information here as
comprehensive as is possible in a review course. It is our
hope that even after you are finished taking the course, you
will find this a useful reference tool to keep on hand.
In
recent years, however, the nation-wide heightened focus on
controlling health care costs, and the increasingly sophisticated
training received by caregivers have led to considerably expanded
roles, especially in the delivery of health care services.
Nursing was among the first of various specialty groups to
take on more patient assessment responsibilities. With the
advent and proliferation of therapist-driven protocols, physicians
have come to depend on both nurses and respiratory care practitioners
for identifying appropriate respiratory care and evaluating
the effects the therapy is having on the patient.
In
recognition of this expanded role for non-physician caregivers,
even the new matrix for the national exam for respiratory
therapists indicates that caregivers should be able to "determine
the appropriateness of the prescribed respiratory care plan
and recommend modifications where indicated...(caregivers
should be able to) analyze available data to determine pathophysiologic
state (of patients), review planned therapies, establish therapeutic
goals, determine appropriateness of prescribed therapies and
goals...(and) recommend changes in therapeutic plans if indicated,
based on (patient) data."
"Patient
data" and how to interpret it is the focus of this continuing
education unit. Nurses have their practice guidelines to
follow regarding assessing the well-being of patients,
and RCPs have their therapist-driven protocols which
are based on respiratory practitioners being able to analyze
available patient data to determine their pathophysiological
state. This requires having excellent observational and clinical
evaluation skills.
Learning Objectives
Upon
successful completion of this course, and given an open-book,
multiple-choice exam, you will be able to correctly answer
a minimum of 90% of the test items requiring you to:
- Identify
and demonstrate methods for conducting a physical assessment
of the patient,
- List
and discuss the important elements of interviewing a patient
and taking a medical history, including how to document
the information.
- Identify
and explain the purposes of chest roentgenography and key
laboratory tests employed in patient assessment, with an
emphasis on pulmonary tests
- Discuss
the procedures and purposes of sputum examinations
- Identify
and explain the techniques for pulmonary function testing
- Identify
and explain the purposes of laboratory tests used in patient
assessment

Evaluation
The
evaluation of patients calls for the application of all the
skills of the trained professional. Some of the more important
characteristics of the patients condition that may be
detected by a careful and skilled observer include: the patients
physical appearance, respiratory status, and even his/her
apparent mental and emotional state.
Evaluation
of those characteristics requires the caregiver to have in-depth
knowledge of respiratory diseases and their symptoms. The
caregivers must also be able to recognize the physical changes
that occur in pulmonary patients, and be aware of the types
of "complaints" those changes generate.
The
health care professional must be aware of the wide variety
of diagnostic tests available today, especially those relating
to lung function, and be able to ascertain and quantify abnormalities
shown on test results. The caregiver is responsible for assessing
patients for changes in cardio-pulmonary status, for performing
an overall physical assessment, and for interpreting available
clinical data including the patients hemodynamics, chest
x-rays, EKGs, and data from lab tests. In brief, caregivers
must be proficient in gathering patient data, analyzing it,
and providing a valid interpretation for other health care
professionals.
Documentation
It
is also important that health care professions know how to
document their findings. One of the most commonly used
formats used for documenting patient data is as follows:
- Record
when the patient was evaluated, including: day, month, year,
and time)
- Document
the original diagnosis, and indicate when the symptoms first
occurred (if available), and record any problems that are
secondary to the primary diagnosis
While the format in which the information is recorded varies
from institution to institution, it generally includes:
- Subjective
assessment: based on the interview with the patient, including
his own observations and descriptions of the complaint or
symptoms.
- Objective
data: based on the information obtained from x-rays, diagnostic
exams, and notes from the physician and nurse
- Patient
evaluation: record the results of the interview, visual
assessment, percussion, auscultation, and palpation
- Document
the original treatment plan, and document the clinical and
therapeutic objectives of that plan
- Patient
response: record how the patient responds to application
of the therapy
- Document
recommendations regarding continuance, modification, or
discontinuance of the therapy; if applicable, record recommendations
for additional tests and the results of communications with
other members of the health care team
- Record
the patient assessment in the procedures column of the patients
Therapy Procedure Log
- Some
of the most useful methods of gathering data regarding patients
involve the interview, history-taking, and physical examination.
While it is at best difficult to separate the three since
they often all occur simultaneously in the clinical setting,
for the purposes of this CEU module we will try to examine
their important characteristics as separate entities.

Patient Interview
The
interview takes place at the very beginning of the relationship
with patients. The practitioner simply proceeds to ask the
patient about the nature of his/her problem or complaint.
This patient interview can reveal important information relating
to symptoms, the patients emotional/mental state, and
his/her own perception of the problem. The interview is when
questions regarding complaints of cough and dyspnea are clarified.
Signs of distress during the interview include: the patient
sitting forward or in a braced position, anxious or fearful
facial expressions, rapid respiratory rates, and interrupted
speech patterns.
The
purposes of the initial patient interview are to establish
rapport, identify the functional status of patient, elicit
assessment data, and introduce therapy. Youve probably
heard it said that "how" you say something is often
as important as "what" you say. In that vein, before
we discuss the types of questions you should ask during the
initial patient interview, lets review interviewing
techniques and how to structure the interview.
A
basic but important aspect of interviewing involves the caregiver
being able to convey genuine concern for the patients
well-being. Empathy towards the patient can be expressed in
several ways. For example, establishing good eye contact during
the interview not only lets patients know you are interested
in what they are saying, but helps the health care professional
control the interview.
Patients
can easily sense when a practitioner is doing the minimum,
or just "doing his job" and has no sincere interest
in their problems. Clinicians who have this approach not only
turn off the patient, but also frequently overlook potentially
significant information. As a result, their assessment of
the patient is incomplete, inaccurate, and often leads to
the prescription of inappropriate or unnecessary treatments.
Another
way caregivers can convey their genuine concern for the patients
condition involves how they ask questions during the interview.
Posing questions that can be answered with a simple "yes"
or "no" is usually inappropriate, counter-productive,
and fails to encourage productive communication. An interview
that employs more open-ended questions calling for extended
responses encourages the patient to "open-up", and
reveals information that facilitates an accurate patient assessment.
When appropriate, the use of touch may also be an effective
means of demonstrating empathy during an interview.
Structuring
the Interview
In
order to increase the chances of a successful outcome for
the interview, even the briefest of patient assessment interviews
needs to have a pre-established structure. The nature and
content of the questions that will be asked during the interview
require an environment that is private and quiet in order
to encourage honest and effective communications.
Prior
to entering a patients room, you should prepare your
thoughts so that youre ready to ask appropriate questions
that will enable you to obtain pertinent clinical information.
If youre well organized, youll be able to avoid
repeating questions and wont forget to ask key questions.
Whenever possible, the setting for the interview should allow
for a face-to-face conversation. You should begin the interview
by addressing the patient by name, introducing yourself, and
explaining your role and the purpose of the interview. This
should start the process of putting the patient at ease regarding
what is going on.
Observing
the patient closely and listening closely during the interview
is crucial to your ability to identify his/her mood, level
of intelligence, and general state of well-being. Acutely
ill or apparently anxious patients may need some reassurances
prior to starting in-depth questioning.
Interview
Techniques
As
an experienced professional accustomed to conducting patient
interviews, you probably have adopted a series of questions
that you have found works well. This discussion is meant as
a review, and may be helpful if youve possibly gotten
into a rut in your questioning routine. There are several
types of questions you can employ to assess patients. A brief
review of the types of questions is helpful since each has
its place in certain situations.
The
most common questions are called direct questions.
These are ones that patients can answer with a simple yes
or no, or with specific, brief information. Direct questions
are most useful in short interviews to assess the patients
progress toward therapeutic goals. These questions keep the
patient focused on relevant topics and help shorten the conversation.
It is possible however, to overuse direct questions, causing
patients to feel overwhelmed and giving them the sense that
you are rushed and arent really concerned about their
condition.
It
is important to word direct questions carefully since
most patients tend to answer yes if they think thats
the answer you want to hear. For example, if you ask patients
whether their breathing has improved today, they may automatically
answer "yes" because they think that is the answer
you want to hear. A better way to phrase the question may
be to ask, "Are you feeling any better today?" If
the patients answer is yes, you can counter by asking,
"In what way do you feel better today?" This gives
the patient an opening for more detailed information without
feeling any pressure from you.
It
is up to you to not only to ask the right questions in a proper
manner, but also to recognize the significance of the patients
responses to your questions. That is what makes open-ended
questions more useful than direct questions. Open-ended
questions tend to encourage patients to be more open and talkative
about their health concerns they are particularly useful for
the initial interview to identify the various symptoms and
details pertaining to their complaints.
Questions
like "Under what conditions do you feel a shortness of
breath?" tend to encourage patients to offer more information
than do direct (and somewhat limiting) questions like "Do
you ever feel shortness of breath?" Open-ended questions,
however, may not result in identifying all the important details
since this type of questioning does not direct the patient.
The most effective and productive interview contains a combination
of direct and open-ended questions.
Interview
Topics
Many
of the questions posed during the initial interview pertain
to the patients medical history, including:
- Demographic
information, including: patients name, date of birth,
nationality, occupation, marital status, religious affiliation,
and referral source.
- Patients
answers and brief self-descriptions of physical condition
to questions posed during the interview, including:
- Chief
complaint: What made the patient decide to seek medical
assistance--in his own words, and your comments.
- Present
illness: Record the patients and your description
of current symptoms, when they first occurred and whether
they have gotten worse or better with time. Be sure to include
a description of the location, frequency and duration of
occurrence, severity of pain, and identification of the
factors that contribute to an increase or diminution of
the symptoms.
Caregivers
should take special note of problems involve patients
cardiopulmonary system, asking him about the following:
- Cough:
Does the patient have a cough? If so, so does he/she describe
it as severe, moderate, or slight? If you observe the cough,
record your evaluation. Ask patients how long theyve
had the cough, when is it the worst, the least. Document
the coughs characteristics: hacking, dry, productive
of mucus or phlegm, etc. If they cough up blood, determine
the exact amount, color, and consistency of the blood.
- If
the patient has Hemoptysis (expectoration or coughing
up of blood or bloody sputum from the lungs), this can be
significant in the diagnosis; however, you need to be aware
not to confuse Hematemesis (vomiting of blood) with
hemoptysis.
- Dyspnea:
Does the patient ever feel short of breath, during rest
or physical activity? Ask him to describe the degree of
shortness of breath on an imaginary scale of one to ten.
Dyspnea
is the subjective sensation of a shortness of breath. The
person with dyspnea consciously experiences symptoms of difficult,
labored, and uncomfortable breathing in conditions other than
heavy exercise. The experience of dyspnea is subjective and
is influenced by the patient's reactions and emotional state
at the time. Only the patient can determine its severity.
Dyspnea
can be either acute or chronic and can be associated with
a vast array of diseases such as respiratory, cardiac, endocrine,
renal, neurologic, metabolic, hematologic, and even psychologic
disturbances. Treatment must be directed to discovering and
treating the underlying cause.
If
the dyspneic episode is acute then every action must be taken
to secure the patient's airway and provide oxygenation and
ventilation. Causes of acute dyspnea may include airway obstruction,
pneumothorax, pulmonary embolus, pulmonary edema, pneumonia,
asthmatic attack, pulmonary hemorrhage, or even anxiety. In
acute cases of dyspnea, the problem will go away when the
underlying cause is resolved.
In
chronic lung disease such as COPD and various fibrotic lung
diseases the dyspnea may never go away. In these cases, the
treatment of the underlying process will not always alleviate
the symptoms of dyspnea. Causes for chronic dyspnea may include
airway disease, lung parenchymal disease, pulmonary vascular
disease, pleural process, chest wall abnormality, anemia,
deconditioning, cardiac disease, thyroid disease, or neuromuscular
disorders.
Clinical
assessment of the patient should be made from a thorough physical
assessment along with a patient history. Using muscles of
respiration is an obvious indication of dyspnea along with
tachycardia, diaphoresis, and tachypnea. A bilateral paradoxical
breathing pattern is often a sign of possible respiratory
failure. Auscultation of the airways will also be important
to reveal constricted airways and consolidation as a cause
for the dyspnea.
Important
questions to ask the patient should include: when the dyspnea
started, whether the onset was gradual or abrupt, where the
patient was, what the patient was doing at the time, severity
of the symptoms, any possible precipitating factors, any changes
in the patient's health status, coughing and sputum production,
and any associated symptoms such as chest pain, change in
consciousness, etc.
A
pulse oxygen saturation reading is a good beginning measurement
along with routine vital signs. This can then be followed
up with more detailed laboratory tests such as arterial blood
gases, blood analysis, and an EKG among other things.
Episodes
of dyspnea can easily lead to feelings of anxiety and panic,
which then creates more shortness of breath. When the patient
feels that he cannot get enough air anxiety increases, which
increases respiratory rate and oxygen demands. This vicious
cycle worsens the dyspnea.
Techniques
to break the cycle of dyspnea will include providing reassurance
that something is being done to provide relief, instructing
the patient to use purse-lip breathing techniques to gain
control of his breathing, maintaining the patient in a Fowler's
position to allow maximum lung expansion, encouraging relaxation
techniques, along with providing medication and oxygen therapy.
American
Thoracic Society Grade of Breathlessness Scale
Grade
Degree - Description of breathlessness
0 None - Not troubled except during strenuous
exercise
1 Slight - Troubled when hurrying on level ground
or walking up a slight
hill
2
Moderate - Walks slower than people of the same
age on level
ground
because of breathlessness or has to stop for
breath
when walking at own pace on level ground
3
Severe - Stops for breath after walking about
100 yards or after a
few minutes on level ground
4
- Very Severe - Too breathless to leave the house or
breathless
when
dressing and undressing
- Wheezing:
This involves emission of a whistling-like sound resulting
from narrowing of the lumen of a respiratory passageway.
Ask and observe if the patient is wheezing. If so, inquire
as to when it appears to occur most and what seems to provoke
it.
- Chest
Pain: Do they experience it? If so, ask where its
located, is the onset sudden, does breathing deeply breathing
or coughing aggravate it?
- Locomotor
System: Does the patient ever experience pain when using
his muscles or moving his joints? Is he currently experiencing
such pain?
- Nervous
System: Ask the patients if they are currently experiencing
any headaches, muscle weakness, dizzy feelings, faintness,
seizures or convulsions, tremors, vertigo, diplopia, paralysis,
paresis, or ataxia.
- Psychiatric
Problems: Ask if they are currently feeling particularly
nervous, stressed, having episodes of depression, having
trouble sleeping or nightmares, or suffering any memory
loss.
- Anorexia
and Weight Loss: Ask if the patient has recently experienced
a loss of appetite, with an attendant loss of weight. This
can be very relevant to making a proper diagnosis of respiratory
problems.
- Night
Sweats: Ask if the patient is experiencing excessive
perspiration during sleep at night. If so, ask specific
questions regarding the location and characteristics of
the perspiration, including odor.
- Digestive
System: Ask if the patients are having trouble digesting
their meals. Are they experiencing nausea, or vomiting?
Does their digestive system involve excess gas or belching,
excessive stomach sounds? Do they have difficulty swallowing,
and do they experience dark or bloody stools?
- Genitourinary
System: Ask if the patients are experiencing any pain
or difficulty urinating, are incontinent, have any renal
stones, or urinary infections.
- Endocrine
System: Ask if the patient is diabetic, has intolerance
to heat or cold, or has recently experienced any change
of voice.

Medical History
Taking
General
Considerations
Remember
that there are two halves to each interview, patient-centered
and caregiver-centered.
|
Caregiver-Centered
|
Patient-Centered
|
|
Caregiver's
Agenda
|
Patient's
Agenda
|
|
Biomedical
Focus
|
Symptom
Focus
|
|
S/B
Caregiver Gathers Data
|
Patient
Tells Story
|
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Opening
the Interview
It
is important to begin each medical interview with a patient-centered
approach.
1.
Set the Stage
o Welcome the patient - ensure
comfort and privacy
o Know and use the patient's
name - introduce and identify yourself
2. Set the Agenda
o Use open-ended questions initially
o Negotiate a list of all issues
- avoid detail!
§
Chief complaint(s) and other concerns
§
Specific requests (i.e. medication refills)
o Clarify the patient's expectations
for this visit - ask the patient "Why
now?"
3. Elicit the Patient's Story
o Return to open-ended questions directed
at the major problem(s)
o Encourage with silence, nonverbal
cues, and verbal cues
o Focus by paraphrasing and summarizing
4. Make the Transition
o Summarize the interview up to that
point
o Verbalize your intention to make
a transition to the physician-centered interview
History
of Present Illness
Primary
History
You
should always begin the caregiver-centered phase of
the interview with "WH" questions (where? what?
when?) directed at the chief complaint(s). Build on the information
the patient has already given you. Flesh out areas of the
story you don't fully understand. Try to quantify whenever
possible (pain on a scale of 1 to 10, number of days instead
of "a while," etc.). Be as specific as possible
and try to record what the patient says accurately, without
interpretation. Address as many of these details as appropriate:
1.
Location
2. Radiation
3. Quality
4. Quantity
5. Duration
6. Frequency
7. Aggravating Factors
8. Relieving Factors
9. Associated Symptoms
10. Effect on Function
Secondary
History
The
secondary history expands on the primary history, especially
any associated symptoms. It is useful to think of the
secondary history as a focused review of systems (see
below). These questions often bring out information that supports
a certain diagnosis or helps you gauge the severity of the
disorder. Unlike the primary history, a certain amount ofinterpretation
(and experience) is necessary. Here are some examples:
Headache
Ask
about nausea and vomiting.
Ask about visual changes.
Ask about the relationship with stress, work, weekends, and
emotions.
Ear
Problems
Ask
about hearing loss or ringing in the ears.
Ask about dizziness or vertigo.
Tertiary
History
The
tertiary history brings in elements of the past medical
history (see below) that have direct bearing on the patient's
condition. By the time you get to the tertiary history you
may already have a good idea of what might be going on. (This
will be fine-tuned by the physical exam.) Here are some examples:
Any
HEENT or Chest Disorder
Does
the patient smoke? How much? How long?
For children, does someone smoke in the home?
Breast
Problems
Is
there a family history of breast cancer?
Abdominal
Pain
Does
the patient smoke? How much? How long?
How much alcohol does the patient consume?
Prior surgery? Has the appendix been removed?
Chest
Pain
Does
the patient smoke? How much? How long?
Did the patient's parents die of a heart attack? At what ages?
Review
of Systems
The
review of systems is just that, a series of questions grouped
by organ system including:
1.
General/Constitutional
2. Skin/Breast
3. Eyes/Ears/Nose/Mouth/Throat
4. Cardiovascular
5. Respiratory
6. Gastrointestinal
7. Genitourinary
8. Musculoskeletal
9. Neurologic/Psychiatric
10. Allergic/Immunologic/Lymphatic/Endocrine
Past
Medical History
The
past medical history is essentially background information
related to the patient's health and well being. A brief past
medical (and social) history often includes these elements:
1. Allergies and Reactions to Drugs (What happened?)
2. Current Medications (Including "Over-the-Counter")
3. Medical/Psychiatric Illnesses (Diabetes, Hypertension,
Depression, etc.)
4. Surgeries/Injuries/Hospitalizations (Appendectomy, Car
Accident, etc.)
5. Immunizations
6. Tobacco/Alcohol/Drug Use
7. Reproductive Status for Females
o Last Menstrual Period
o Last Pelvic Exam/Pap Smear
o Pregnancies/Births/Contraception
8. Birth History/Developmental Milestones for Children
9. Marital/Family Status
10. Occupation/Exposures
For
more on Past Medical History, be sure to ask the patient for
information regarding:
- Past
Illnesses, including: recurrent episodes of pulmonary infections,
infectious diseases, infantile eczema, atopic dermatitis,
accidents, allergic rhinitis, or co-existing conditions
such as diabetes, hypertension, thyroid, or other glandular
disorders should be noted. Other illnesses to inquire about:
rheumatic fever, diabetes, pneumonia, tuberculosis, arthritis,
jaundice, kidney or heart trouble, ulcer, phlebitis, anemia,
asthma, hay fever, hives, cancer, measles, adenoviral infections,
or pertussis in childhood which may predispose the individual
to bronchiectasis. Is the patient taking any medications,
such as: antihypertensives, steroids, bronchodilators, heart
medications, or diuretics.
- Past
Hospitalizations: you also need to document any past hospitalizations
for infection or surgery (especially chest procedures which
may be the cause of cardiorespiratory insufficiency). Also
inquire about dental extractions, upper respiratory tract
surgery, or aspiration of foreign bodies, because they may
cause pulmonary abscesses.
- Allergies:
finally you should ask patients if they have any allergies,
for example: to animals, flowers, perfumes, dust, drugs
and foods which may trigger allergic reactions.
Family History: You should inquire about the patients
familial disease history (particularly hereditary diseases,
such as cystic fibrosis and asthma), and illnesses such
as TB. You should also determine the patients marital
status, and the health status of a spouse.
Social
and Environmental History: Is the information regarding the
patients background and living habits that may be associated
with the development of illness. Areas where the patient has
worked, lived, or traveled should be listed, with the amount
of time spent in each area. In addition, your interview should
cover the following:
- Patients
level of education and general economic circumstances
- Military
service experience
- Occupational
history: Should include the duration of each job. It is
important to note exposure to coal dust, asbestos, cloth
or wood fibers, or toxic gases. Also, be sure to inquire
as the level of stress they feel on the job.
- Activities:
Social, religious, hobbies and habits. Do they engage in
any hazardous activities? Ask them to describe their general
diet, sleeping patterns. Are they having any problems with
insomnia? Is adding pillows for sleeping or sleeping in
a recliner common? Do they exercise, use tobacco, alcohol,
coffee, special drugs (laxatives, sedatives, psychotropics)?

Observation
Observation
of the patient, which is the initial phase of the physical
examination, actually begins during the interview and needs
to be conducted meticulously. Be aware that there will inevitably
be some overlap of the information gleaned during the interview,
observation, and subsequent hands-on physical examination.
All three yield valuable information.
The
observation should begin with the caregivers glance
around the patients room that often can tell you a lot
about the clinical situation. Some of the more revealing items
to look for include the presence of isolation signs and supplies,
various monitors or equipment, or chest tubes.
The
caregiver should observe the rate, rhythm and frequency of
the patients respiration during exercise and at rest.
It is also important to observe the shape of the patients
chest, and take note of whether or not the patient needs to
use accessory muscles of respiration.
normalities
in the formations of the bony thorax and spine (such as kyphosis,
pectus excavatum, scoliosis, or lordosis) should also be noted.
It is important to take note the patients bed. For example,
if the bed is in the Trendelenburg position, it can be suggestive
of the existence of hypotension. A bed locked in an upright
position or one that has an unusual number of pillows can
suggest orthopnea resulting from CHF/pulmonary edema.
The
patients position in the bed can also be revealing.
For example, patients with severe lung disease tend to avoid
lying flat in bed because they generally have difficulty breathing
in that position.
Many
patients who are experiencing excess work of breathing brace
their upper torso by resting their arms on the bedside table
or holding on to the side rails in order to get increased
leverage for the accessory muscles of respiration. Air trapping
in COPD patients flattens their diaphragm, so they can frequently
be seen in this position because they rely on the upper chest
muscles to facilitate breathing.
Observing
for Abnormalities
Skin:
Observation begins with the skin and mucus membrane color,
which indicates oxygenation. If the lips or nail beds have
orange, green, or yellow tints, the patient may have impaired
liver function. Flushed skin indicates either a fever or high
blood pressure. Anemic patients have very pale skin, and diaphoresis
(sweating) can be caused by an increase in sympathetic discharge
or increased work of breathing
The caregiver should also look for evidence of cyanosis. Cyanosis
is a bluish tint of the skin and mucous membranes due to reduced
hemoglobin in the subpapillary venous plexus. The amount of
reduced hemoglobin depends on the hemoglobin concentration
and oxygen saturation. This nonspecific symptom is related
to either hypoxemia or decreased perfusion. Detecting cyanosis
is often made difficult by available lighting and the patients
normal skin color. Cyanosis becomes visible to most observers
when the amount of reduced hemoglobin in the capillary blood
exceed 5 to 6 g/dL. This may be due to a reduction in either
arterial or venous oxygen content or both. When the arterial
hemoglobin saturation drops to 75% or less, most observers
see cyanosis in the mucous membranes of the lips and mouth,
as well as the fingers.
Face,
Head and Neck: See if the patients face is pale
or flushed, scarred, swollen, or flabby. Patient distress
(respiratory distress, cyanosis, or plethora) can be estimated
from facial expressions. Head size, shape, contour, and symmetry
are all important to take note of. Also see if there seems
to be any tenderness over sinuses or mastoids. Observe any
rigidity or limitation of motion in the patients neck.
Note abnormal pulsation, scars, masses, enlarged salivary
glands, or lymph nodes. Describe the thyroid gland, position
of trachea, and note carotid and jugular pulses. Jugular venous
distension is often due to congestive heart failure, and distention
of the jugular veins during expiration can be due to severe
obstructive lung disease.
- Ear,
Nose, Mouth, and Throat: Check hearing acuity, noting
any discharge from the ears, and briefly describe condition
of ear drums. Note nasal airway obstructions, septal deviation,
discharge, condition of mucosa, and polyps. Check breath
odor, color and appearance of lips, tongue, gums condition
of teeth, dentures, appearance of mucosa. Describe the palate,
uvula, tonsils, and posterior pharynx when indicated, and
record findings of examination of nasopharynx and larynx.
Check for difficulty with a sore throat, hoarseness, speech
defect, difficulty swallowing, or tonsillitis.
- Eyes:
Respiratory distress can affect the patients pupils.
Pupillary size can be affected by cerebral oxygenation,
and indirectly by cardiac output.
Hands and Ankles: Clubbing is a painless, uniform
enlargement of the terminal segment of a finger or toe,
and is indicative of dilating peripheral vessels and an
increase in subcutaneous tissue as a compensatory mechanism
for chronic, severe hypoxemia. In this condition a change
in the angle between the nail and proximal skin to 180°
or greater occurs. In the early stages its difficult
to diagnose, but in its later stages diagnosis is relatively
easy. The normal angle is 160° to 165° for fingers,
and 175° for thumbs. Clubbing is said to be present
if the hyponychial angle is increased more than 187°
to 209°. Ankle edema is important to note because it
indicates the possibility of venous return, peripheral vascular
disease, fluid overload, and even heart disease.

The Actual Physical
Examination of the Patient
Introduction
The
patient interview and the caregiver's initial observations
yield a great deal of valuable assessment information. The
actual physical examination of the pulmonary patient, however,
is most valuable to facilitate the caregiver's accurate evaluation
of the patients condition and subsequent prescription
of a treatment protocol.
Vital
Signs
One
of the most important aspects of the actual hands-on
physical examination includes checking the patients
vital signs.
The
vital signs are a nonspecific but necessary part of any physical
examination, and assessment of the vital signs is the most
frequent evaluation technique performed in the clinical setting.
The patients vital signs provide crucial information
and clues regarding the patients overall health status,
and his/her response to treatments.
Many
times during a physical examination, the measuring of the
vital signs gives initial evidence of an abnormality. The
four basic vital signs are body temperature, pulse rate, blood
pressure and respiratory rate. While an in-depth discussion
of the vital signs is beyond the scope of this CEU, checking
of vital signs should always be considered as part of a patient
assessment.
Equipment
Needed
- A
Stethoscope
- A
Blood Pressure Cuff
- A
Watch Displaying Seconds
- A
Thermometer
General
Considerations
- The
patient should not have had alcohol, tobacco, caffeine,
or performed vigorous exercise within 30 minutes of the
exam.
- Ideally
the patient should be sitting with feet on the floor and
his back supported. The examination room should be quiet
and the patient comfortable.
- History
of hypertension, slow or rapid pulse, and current medications
should always be obtained.
Heartbeat
To
begin the assessment of vital signs, the caregiver needs to
be adept at taking the patients pulse. A pulse indicates
a heartbeat and can be felt at any of the patients arteries.
Documentation of the patients pulse should include the
frequency, regularity, and quality of the heartbeat. Pulses
monitored in adults include the radial, carotid, or femoral
pulses. In children and infants, the brachial pulse is preferred.
In the documentation process, it is important to note the
rate per minute, as well as the regularity and quality of
the pulse.
The
amount of oxygen being delivered to the patients tissues
is dependent on the hearts ability to pump oxygenated
blood through the circulatory system. The amount pumped per
minute, cardiac output, is a direct function of heart rate
and stroke volume. When the oxygen content of arteries dips
below normal, often as a result of lung disease, the patients
heart attempts to maintain normal oxygen delivery by increasing
the cardiac output. This is achieved by increasing the heart
rate.
The
patients radial artery is most commonly used to assess
the pulse rate. The number of times the heart beats per minute
is measured by counting the pulse in the artery. The caregiver
places the second and third finger pads on the radial pulse
to count for about one minute. Be careful not to hold the
patients wrist too far above the heart because that
can make obtaining an accurate pulse difficult. The normal
range for adult heart rates is between 60-100 beats per minute
(bpm). The average adult pulse rate is 72/bpm.
A
heart rate slower than 60/bpm is called bradycardia, while
tachycardia is a rate greater than 100/bpm. A normal pulse
beats in consistent intervals, and when the interval varies
from beat to beat, the pulse is considered to be irregular.
The
pulse rate is influenced by several factors, with exercise
being the most obvious. With increased activity, the heartbeat
increases 20-30 beats per minute to meet the bodys needs.
It should return to normal within 3 minutes after the activity
has ceased. The heart rate also increases in response to fear,
anxiety, low blood pressure, anemia, fever, hypoxia, and some
medications and for many other reasons. Heart rate decreases
with hypothermia, certain arrhythmias, certain medications
and other reasons.
Remember
that spontaneous ventilation can influence pulse strength
(amplitude) changes. A significant decrease in pulse amplitude
during inhalation is known as pulsus paradoxus (paradoxical
pulse). This is common in patients afflicted with obstructive
pulmonary disease, particularly those experiencing an acute
asthma attack. Pulsus paradoxus also signals the possible
existence of mechanical restriction of the hearts pumping
action, such as is seen in constrictive pericarditis or cardiac
tamponade. Taking a blood pressure measurement best assesses
this condition. An alternating succession of strong and weak
pulses, pulsus alternans, suggests left- sided heart failure
and is not related to the presence of any respiratory diseases.
Evaluating
the carotid, femoral, brachial, temporal, popliteal, posterior
tibial, and dorsalis pedis can also assess the patients
pulse. The carotid and femoral pulse should be used when the
blood pressure is abnormally low. To find the carotid pulse,
locate the larynx with the tips of your first two or three
fingers, slide your fingers away from the larynx (Adams
apple) toward the groove between the trachea and the large
neck muscles, and feel for the pulse. Move your fingertips
around until you find the strongest point and feel the pulse.
Never use your thumb because it has a pulse of its own and
could be mistaken for the patients pulse. Count the
pulse rate and note whether it is strong, weak, regular or
irregular.
If
the carotid site is used, you should take care to avoid the
carotid sinus area because it can evoke a strong parasympathetic
response, causing bradycardia or asystole. To obtain a femoral
pulse, visualize the crease between the leg and the abdomen,
place the tips of your first two or three fingers at the midpoint,
and feel for the pulse.
1.
Sit or stand facing your patient.
2. Grasp the patient's wrist with your free (non-watch bearing)
hand (patient's right with your right
or patient's left with your left). There is no
reason for the patient's arm to be in an awkward position,
just imagine you're shaking hands.
3. Compress the radial artery with your index and middle fingers.
4. Note whether the pulse is regular or irregular:
o Regular - evenly spaced beats,
may vary slightly with respiration
o Regularly Irregular - regular
pattern overall with "skipped" beats
o Irregularly Irregular - chaotic,
no real pattern, very difficult to measure
rate accurately
5. Count the pulse for 15 seconds and multiply by 4.
6. Count for a full minute if the pulse is irregular.
7. Record the rate and rhythm.
Interpretation
- A
normal adult heart rate is between 60 and 100 beats per
minute.
A pulse greater than 100 beats/minute is defined to be tachycardia.
Pulse less than 60 beats/minute is defined to be bradycardia.
Tachycardia and bradycardia are not necessarily abnormal.
Athletes tend to be bradycardic at rest (superior conditioning).
Tachycardia is a normal response to stress or exercise.
Blood
Pressure
Blood
pressure is an indication of how well the heart is pumping,
how much blood it pumps, and how efficiently the job is performed.
The pressure is the pressure of the blood against the walls
of the blood vessels.
The
force exerted on the walls of the arteries as blood pulses
through them is called the arterial blood pressure. Arterial
systolic blood pressure represents the peak force that is
exerted during the contraction of the hearts left ventricle.
Diastolic pressure indicates the force that remains after
relaxation. Pulse pressure is the variance between systolic
and diastolic pressures. For example, if systolic pressure
is 120 and diastolic pressure is 100, the pulse pressure is
20. Normal pulse pressure ranges between 35-40 mm Hg. When
the pulse pressure measures less than 30 mm Hg, peripheral
pulse is difficult to detect.
On
the other hand, the patients blood pressure is determined
by: the force of the left ventricular contraction, the systemic
vascular resistance, and the blood volume. Normal systolic
pressure ranges from 95-140 mm Hg, with an average of about
120 mm Hg. Normal diastolic pressure ranges from about 60-90
mm Hg, with the average norm being 80 mm Hg. Blood pressure
is recorded as a fraction, by listing the systolic pressure
over the diastolic pressure. For example, normal blood pressure
is recorded as being 120/80 mm Hg.
Blood
pressure rises or drops for a variety of reasons. Hypotension
is defined as a drop in blood pressure to a measurement of
less than 95/60 mm Hg. The most common causes of hypotension
include: ventricular failure, peripheral vasodilatation, or
low blood volume. Vital body organs receive inadequate blood
flow in patients with hypotension. Inadequate circulation
can impair O2 delivery to the tissues, causing tissue hypoxia
to occur. As a result, it is important that prolonged hypotension
be prevented.
When
persons with normal blood pressure sit or stand up, blood
pressure is relatively unaffected. However, similar actions
may cause an abrupt drop in blood pressure among hypovolemic
patients. This condition, which is referred to as postural
hypotension, can be confirmed by measure the patients
blood pressure in both the supine and sitting positions.
Sudden
decreases in arterial blood pressure caused by postural hypotension
can decrease cerebral blood flow, leading to syncope,
or fainting. Treatment of postural hypotension involves administration
of fluid or vasoactive drugs. It is important that untreated
or unresponsive postural hypotension be considered when moving
or ambulating a patient.
The systolic blood pressure generally decreases slightly with
normal inhalation; however, a drop of more than 6-8 mm Hg
during resting inhalation is abnormal and referred to as paradoxical
pulse. Paradoxical pulse is caused by intrathoracic pressure
swings created by the respiratory muscles during breathing.
Negative intrathoracic pressure during inspiration assists
venous return to the right ventricle (RV), however it impedes
arterial outflow from the left ventricle (LV). Increased venous
return increases RV pressures, thus restricting LV filling.
This in turn reduces LV stroke volume and decreases systolic
blood pressure during inhalation. Palpation may indicate the
presence of paradoxical pulse, but it can only be quantified
by auscultatory measurement.
Increases
in patient blood pressure can have even more serious consequences.
Blood pressure that consistently measures above 140/90 mm
Hg is referred to as hypertension, which is usually caused
by high systemic vascular resistance. A less common cause
of hypertension is the increased force of ventricular contraction.
Hypertension that is severe often results in congestive heart
failure, central nervous system abnormalities, uremia, or
cerebral hemorrhage leading to the patient suffering a stroke.
Measuring
the patients blood pressure is most commonly accomplished
the auscultatory method. This involves the use of a stethoscope
and a sphygmomanometer. Be sure to check the stethoscope to
be sure its in good working order prior to use. The
sphygmomanometer measures arterial blood pressure, and consists
of a manometer containing a scale for registering pressure
as well as an inflatable badder surrounded by a covering known
as a cuff
Remember that cuffs come in various sizes, and that it is
crucial that the proper-size cuff be used. Using the wrong-size
cuff can cause erroneous blood pressure readings to be obtained.
For example, if the cuff is too narrow for the patients
upper arm, the reading obtained will be falsely high. A regular-sized
cuff should be used if the arms circumference is less
than 13 inches, arms with greater than a 13 inch circumference
require use of a large-size cuff, and pediatric patients or
adults with extremely small arms require use of a pediatric
cuff.
When
the caregiver applies the cuff to the patients upper
arm and pressurizes it to exceed systolic blood pressure,
brachial blood flow is stopped. As the cuffs pressure
is decreased slowly (at a rate of about 2-3 mm Hg per second)
to the point just below systolic pressure, blood flow intermittently
passes the obstruction. This partial obstruction of blood
flow creates vibrations and turbulence called Korotkoff
sounds, which can be heard by placing the stethoscope
over the brachial artery distal to the obstruction.
At
the point at which the first Korotkoff sounds are heard, systolic
blood pressure is recorded. The point at which the sounds
become muffled is the diastolic pressure, and this muffling
is the final change in the Korotkoff sounds prior to their
disappearance. If the muffling and cessation of the sounds
occur at a wide interval, all three pressures should be recorded
(120/80/60).
Besides
using the wrong-sized cuff, other mistakes that cause erroneously
high blood pressure measurements include:
- Cuff
applied either too tightly or too loosely
- Excessive
pressure placed in the cuff during measurement
- Inflation
pressure held in the cuff
Incomplete
deflation of cuff between measurements
Extraneous
room sounds, ventilators, static electricity, or the presence
of an auscultatory gap may also cause errors in measurement
of the patients blood pressure. The auscultatory gap
consists of a 20-40 mm Hg drop with no sound between the first
systolic sound and the continuous pulse sound. Inflating the
cuff until the palpated radial pulse can no longer be felt
can help prevent missing the opening snap. When the auscultatory
gap is heard, both the opening snap pressure and pressure
at which continuous pulses are heard should be recorded (160/140/80).
Position the patient's arm so the antecubital fold is level
with the heart. Support the patient's arm with your arm or
a bedside table.
1.
Center the bladder of the cuff over the brachial artery approximately
2 cm above the antecubital fold.
Proper cuff size is essential to obtain an
accurate reading. Be sure the index line falls between the
size marks when you apply the cuff.
Position the patient's arm so it is slightly
flexed at the elbow.
2.
Palpate the radial pulse and inflate the cuff until the pulse
disappears. This is a rough estimate
of the systolic pressure.
3.
Place the stethoscope over the brachial artery.
4.
Inflate the cuff to 30 mmHg above the estimated systolic pressure.
5.
Release the pressure slowly, no greater than 5 mmHg per second.
6.
The level at which you consistently hear beats is the systolic
pressure.
7.
Continue to lower the pressure until the sounds muffle and
disappear. This is the diastolic pressure.
8.
Record the blood pressure as systolic over diastolic ("120/70"
for example).
Interpretation
- Higher
blood pressures are normal during exertion or other stress.
Systolic blood pressures below 80 may be a sign of serious
illness or shock.
- Blood
pressure should be taken in both arms on the first encounter.
If there is more than 10 mmHg difference between the two
arms, use the arm with the higher reading for subsequent
measurements.
- It
is frequently helpful to retake the blood pressure near
the end of the visit. Earlier pressures may be higher due
to the "white coat" effect.
- Always
recheck "unexpected" blood pressures yourself.
|
Blood
Pressure Classification in Adults
|
|
Category
|
Systolic
|
Diastolic
|
|
Normal |
<140
|
<90 |
|
Isolated Systolic Hypertension |
>140 |
<90 |
|
Mild Hypertension |
140-159 |
90-99 |
|
Moderate Hypertension |
160-179 |
100-109 |
|
Severe Hypertension |
180-209 |
110-119 |
|
Crisis Hypertension |
>210 |
>120 |
|
- In
children, pulse and blood pressure vary with the age. The
following table should serve as a rough guide:
|
Average
Pulse and Blood Pressure in Normal Children
|
|
Age
|
Birth
|
6mo
|
1yr
|
2yr
|
6yr
|
8yr
|
10yr
|
|
Pulse
|
140
|
130
|
115
|
110
|
103
|
100
|
95
|
|
Systolic
BP
|
70
|
90
|
90
|
92
|
95
|
100
|
105
|
|
Notes
1.
For more information refer to A Guide to Physical Examination
and History Taking, Seventh Edition
by Barbara Bates, published by Lippincott
in 1999.
2. Unlike pulse, respirations are very much under voluntary
control. If you tell patients you
are counting their breaths, they may change their breathing
pattern. You cannot tell someone to "breathe normally,"
normal breathing is involuntary.
3. With an irregular pulse, the beats counted in any 15-second
period may not represent the overall
rate. The longer you measure, the more these
variations are averaged out.
4. Do not rely on pressures obtained using a cuff that
is too small or too large. This is
frequently a problem with obese or muscular adults where the
regular cuff is too small. The pressure recorded will most
often be 10, 20, even 50 mmHg too
high! Finding a large cuff may be inconvenient,
but you will also "cure" a lot of high blood pressure.
5. Maximum Cuff Pressure - When the baseline blood pressure
is already known or hypertension is
not suspected, it is acceptable in adults to inflate
the cuff to 200 mmHg and go directly to auscultating the blood
pressure. Be aware that there could
be an auscultory gap (a silent interval
between the true systolic and diastolic pressures).
6. Bell or Diaphragm? - Even though the Korotkoff sounds are
low frequency and should be heard
better with the bell, it is often difficult to
apply the bell properly in the antecubital fold. For this
reason, it is common practice to use
the diaphragm when taking blood pressure.
7. Systolic Pressure - In situations where auscultation is
not possible, you can determine systolic
blood pressure by palpation alone. Deflate the cuff
until you feel the radial or brachial pulse return. The pressure
by auscultation would be approximately
10 mmHg higher. Record the pressure
indicating it was taken by palpation (60/palp).
8. Diastolic Pressure - If there is more than 10 mmHg difference
between the muffling and the disappearance
of the sounds, record all three numbers
(120/80/45).
Temperature
The
temperature of the body indicates the amount of heat produced
by the activity of changing food into energy. The body loses
heat through perspiration, breathing, and the elimination
of body wastes. The balance between heat production and heat
loss determines the bodys temperature. The average normal
body temperature is 98.6° F, with daily variances of about
1° F.
There
are a variety of factors, including exercise and infections
that can cause body temperature to increase. When temperature
increases, CO2 production and, O2 consumption also increase.
For example, with every 1° rise in temperature CO2 production
and O2 consumption increase by nearly 10%. In turn, breathing
frequency needs to increase in order to adequately compensate.
Logically, declines in temperature produce just the opposite
effect. A mild infection may cause the temperature to rise
to 102° F, while a temperature over 106° F can be
fatal.
Temperatures
below normal are called hypothermia. Collapse will occur at
96.0° F, and death normally occurs if temperature goes
below 93.0° for any length of time. The most common cause
of hypothermia is extensive and prolonged exposure to cold
temperatures in the environment. Hypothermia can also be caused
by severe head injuries involving damage to the hypothalamus,
an important regulatory agent for body temperature. As the
body temperature falls to low levels, the hypothalamus initiates
shivering to generate heat, and vasoconstriction to conserve
heat. Patients with hypothermia may exhibit slow and shallow
breathing and reduced pulse rates. Mechanical ventilators
in the control mode may need to be significantly adjusted
in the rate and depth of tidal volumes delivered as the patients
temperature rises and falls below normal.
The
bodys temperature is kept normal by balancing heat production
with loss of heat. If the body did not discharge heat generated
by metabolism, the temperature would rise about 2° F per
hour. Peripheral vasodilatation, sweating, and respiratory
ventilation help dissipate body heat.
Temperature
can be measured is several different ways:
- Oral
with a glass, paper, or electronic thermometer (normal 98.6F/37C)
- Axillary
with a glass or electronic thermometer (normal 97.6F/36.3C)
- Rectal
or "core" with a glass or electronic thermometer
(normal 99.6F/37.7C)
- Aural
(the ear) with an electronic thermometer (normal 99.6F/37.7C)
Of these, axillary is the least and rectal is the most accurate.
The
patients body temperature is most commonly measured
by using a glass or electronic thermometer at the site of
the mouth, axilla, or rectum. The temperature measured at
the rectal site most closely approximates the actual core
temperature of the patients body. The most acceptable
site for measuring adult temperatures is the mouth. If patients
have been smoking or ingesting hot or cold liquid, taking
of the temperature should be delayed for about 15 minutes
to avoid inaccurate measurements
Oral
temperatures should not be taken on patients breathing heated
or cooled aerosol via facemasks because there is a tendency
for erroneous measurements. However, oral temperatures are
unaffected by simple oxygen administration via nasal cannula
or mask. It is not necessary to remove the oxygen or use the
rectal site on patients receiving simple oxygen therapy.
Respiration
Normal
breathing frequency of an adult is 12-20 breaths per minute.
The respiratory rate is counted by watching the patients
abdomen or chest wall move in and out during respiration.
The practiced caregiver should be able to easily identify
even the subtlest breathing movements of patients at rest.
It may be necessary in some cases to place a hand on the patients
abdomen to confirm the breathing rate. In any event, caregivers
should avoid letting the patient become aware that their breathing
rate is being counted. One way to accomplish this is to count
the respiratory rate after evaluating the pulse, keeping the
fingers on the artery.
Exercise,
fever, hypoxia, anxiety, pain, metabolic acidosis, and an
increase in the work of breathing can increase frequency (e.g.:
pulmonary fibrosis). Frequency decreases from head trauma,
hypothermia, and ventilatory depressing medications.
Breathing
patterns and effort should also be observed. Any respiratory
abnormalities that increase the work of breathing usually
cause the accessory muscles of ventilation to become active,
even at rest. A significant reduction in lung volume, as that
seen in atelectasis, usually results in rapid, shallow breathing.
The greater the loss of lung volume, the higher the patients
respiratory rate.
Common
types of abnormalities seen in patients rate and rhythm
of breathing include:
- Tachypnea:
Breathing that is faster than normal and usually more shallow.
- Bradypnea:
An abnormally slow rate of respiration
- Hyperpnea:
Deep breathing
- Hyperventilation:
Ventilation in excess of that necessary to meet metabolic
needs
- Cheyne-Stokes
Respirations: An abnormal breathing pattern characterized
by alternating periods of apnea and periods of rising, then
falling tidal volumes
- Kussmauls
Breathing: Deep gasping type of respiration associated
with severe diabetic acidosis and coma
- Obstructive
Breathing: In obstructive lung disease, expiration is
prolonged because of increased airway resistance. If the
patient must increase his respiratory rate, he lacks sufficient
time for full expiration. His chest over expands (air trapping)
and his breathing becomes shallower.
- Biots
Breathing: Characterized by several short breaths followed
by long irregular periods of apnea
- Best
done immediately after taking the patient's pulse. Do not
announce that you are measuring respirations.
1. Without letting go of the patients wrist begin to observe
the patient's breathing. Is it normal or labored?
2. Count breaths for 15 seconds and multiply this number
by 4 to yield the breaths per minute.
In
adults, normal resting respiratory rate is between 14-20 breaths/minute.
Rapid respiration is called tachypnea
While
there is some overlap between the following sections on examining
the back and extremities and the material in the chest examination
section, both are important aspects of the patient assessment
process:
Examination
of the Extremities and Back
Equipment
Needed
- None
General Considerations
- The
patient should be undressed and gowned as needed for this
examination.
- Some
portions of the examination may not be appropriate depending
on the clinical situation (performing range of motion on
a fractured leg for example).
- The
musculoskeletal exam is all about anatomy. Think of the
underlying anatomy as you obtain the history and examine
the patient.
- When
taking a history for an acute problem always inquire about
the mechanism of injury, loss of function, onset of swelling
(< 24 hours), and initial treatment.
- When
taking a history for a chronic problem always inquire about
past injuries, past treatments, effect on function, and
current symptoms.
- The
cardinal signs of musculoskeletal disease are pain, redness
(erythema), swelling, increased warmth, deformity, and loss
of function
- Always
begin with inspection, palpation and range of motion, regardless
of the region you are examining. Specialized tests are often
omitted unless a specific abnormality is suspected. A complete
evaluation will include a focused neurologic exam of the
effected area.
Regional
Considerations
- Remember
that the clavicle is part of the shoulder. Be sure
to include it in your examination.
- The
patella is much easier to examine if the leg is extended
and relaxed.
- Be
sure to palpate over the spinous process of each
vertebrae.
- It
is always helpful to observe the patient standing and
walking.
- Always
consider referred pain, from the neck or chest to
the shoulder, from the back or pelvis to the hip, and from
the hip to the knee.
- Pain
with, or limitation of, rotation is often the first
sign of hip disease.
- Diagnostic
hints based on location of pain
| |
Back
|
Side
|
Front
|
|
Shoulder
Pain
|
Muscle
Spasm
|
Bursitis
or Rotator Cuff
|
Glenohumeral
Joint
|
|
Hip
Pain
|
Sciatica
|
Bursitis
|
Hip
Joint
|
|
Inspection
1.
Look for scars, rashes, or other lesions.
2. Look for asymmetry, deformity, or atrophy.
3. Always compare with the other side.
Palpation
1.
Examine each major joint and muscle group in turn.
2. Identify any areas of tenderness.
3. Identify any areas of deformity.
Range
of Motion
Start
by asking the patient to move through an active range of motion
(joints moved by patient). Proceed to passive range of motion
(joints moved by examiner) if active range of motion is abnormal.
Active
1.
Ask the patient to move each joint through a full range of
motion.
2. Note the degree and type (pain, weakness, etc.) of any
limitations.
3. Note any increased range of motion or instability.
4. Always compare with the other side.
Proceed
to passive range of motion if abnormalities are found.
1.
Ask the patient to relax and allow you to support the extremity
to be examined.
2. Gently move each joint through its full range of motion.
3. Note the degree and type (pain or mechanical) of any limitation.
4. If increased range of motion is detected, perform special
tests for instability as appropriate.
Always
compare with the other side.
Specific
Joints
- Fingers
- flexion/extension; abduction/adduction
- Thumb
- flexion/extension; abduction/adduction; opposition
-
Wrist - flexion/extension; radial/ulnar deviation
- Forearm
- pronation/supination (function of BOTH elbow and wrist)
- Elbow
- flexion/extension
- Shoulder
- flexion/extension; internal/external rotation; abduction/adduction
(2/3 glenohumeral joint, 1/3 scapulo-thoracic)
- Hip
- flexion/extension; abduction/adduction; internal/external
rotation
- Knee
- flexion/extension
- Ankle
- flexion (plantarflexion)/extension (dorsiflexion)
- Foot
- inversion/eversion
- Toes
- flexion/extension
- Spine
- flexion/extension; right/left bending; right/left rotation
Vascular
Pulses
1.
Check the radial pulses on both sides. If the radial pulse
is absent or weak, check the brachial
pulses.
2. Check the posterior tibial and dorsalis pedis pulses on
both sides. If these pulses are absent
or weak, check the popliteal and femoral pulses.
Capillary
Refill
1.
Press down firmly on the patient's finger or toenail so it
blanches.
2. Release the pressure and observe how long it takes the
nail bed to "pink" up.
3. Capillary refill times greater than 2 to 3 seconds suggest
peripheral vascular disease, arterial
blockage, heart failure, or shock.
Edema,
Cyanosis, and Clubbing
1.
Check for the presence of edema (swelling) of the feet and
lower legs.
2. Check for the presence of cyanosis (blue color) of the
feet or hands.
3. Check for the presence of clubbing of the fingers.
Lymphatics
1.
Check for the presence of epitrochlear lymph nodes.
2. Check for the presence of axillary lymph nodes.
3. Check for the presence of inguinal lymph nodes.
Special Tests
Upper
Extremities
Snuffbox
Tenderness (Scaphoid)
1.
Identify the "anatomic snuffbox" between the extensor
pollicis longus and brevis (extending
the thumb makes these structures more prominent).
2. Press firmly straight down with your index finger or thumb.
Any tenderness in this area is highly
suggestive of scaphoid fracture.
Drop
Arm Test (Rotator Cuff)
1.
Start with the patient's arm abducted 90 degrees.
2. Ask the patient to slowly lower the arm.
If the rotator cuff (especially the
supraspinatus) is torn, the patient will
be unable to lower the arm slowly and smoothly
Impingement
Sign (Rotator Cuff)
1.
Start with the patient's arm relaxed and the shoulder in neutral
rotation.
2. Abduct the arm to 90 degrees.
3. Significant shoulder pain as the arm is raised suggests
an impingement of the rotator cuff
against the acromion.
Flexor
Digitorum Superficialis Test
1.
Hold the fingers in extension except the finger being tested.
2. Ask the patient to flex the finger at the proximal interphalangeal
joint.
3. If the patient cannot flex the finger, the flexor digitorum
superficialis tendon is cut or non-functional.
Flexor
Digitorum Profundus Test
1.
Hold the metacarpophalangeal and proximal interphalangeal
joints of the finger being tested
in extension.
2. Ask the patient to flex the finger at the distal interphalangeal
joint.
If
the patient cannot flex the finger, the flexor digitorum profundus
tendon is cut or non-functional
Vascular
and Neurologic Tests
Allen
Test (Radial/Ulnar Arteries)
1.
Ask the patient to make a tight fist.
2. Compress both the ulnar and radial arteries to stop blood
flowing to the hand.
3. Ask the patient to open the hand.
4. Release pressure on the ulnar side. The hand should "pink"
up in a few seconds unless the ulnar
artery is occluded.
Phalen's
Test (Median Nerve)
 |
1. |
Ask the patient to press the backs of the hands together
with the wrists fully flexed (backward praying). |
| 2. |
Have
the patient hold this position for 60 seconds and then
comment on how the hands feel. |
| 3. |
Pain,
tingling, or other abnormal sensations in the thumb, index,
or middle fingers strongly suggest carpal tunnel syndrome
Repeat the process for the radial artery as indicated. |
Tinel's
Sign (Median Nerve)
1.
Use your middle finger or a reflex hammer to tap over the
carpal tunnel.
2. Pain, tingling, or electric sensations strongly suggest
carpal tunnel syndrome.
Lower
Extremities
Collateral
Ligament Testing
1.
The patient should be supine with the legs resting on the
exam table.
2. Hold the leg to be examined in 20-30 degrees of flexion.
3. Place one hand laterally just below the knee. Grasp the
leg near the ankle with your other
hand.
4. Gently push with both hands in opposite directions to stress
the knee.
5. If the knee joint "opens up" medially, the medial
collateral ligament may be torn.
6. Reverse your hands and repeat the stress.
7. If the knee joint "opens up" laterally, the lateral
collateral ligament may be torn.
Lachman
Test (Cruciate Ligaments)
1.
Ask the patient to lie supine on the exam table.
2. Grasp the thigh with one hand and the upper tibia with
the other. Hold the knee in about
15 degrees of flexion.
3. Ask the patient to relax and gently pull forward on the
tibia.
4. The normal knee has a distinct end point. If the tibia
moves out from under the femur, the
anterior cruciate ligament may be torn.
5. Repeat the test using posterior stress.
6. The normal knee has a distinct end point. If the tibia
moves back under the femur, the posterior
cruciate ligament may be torn.
Anterior/Posterior
Drawer Test (Cruciate Ligaments)
1.
Ask the patient to lie supine on the exam table with knees
flexed to 90 degrees and feet flat
on the table.
2. Sit on or otherwise stabilize the foot of the leg being
examined.
3. Grasp the leg just below the knee with both hands and pull
forward.
4. If the tibia moves out from under the femur, the anterior
cruciate ligament may be torn.
5. Without changing the position of your hands, push the leg
backward.
6. If the tibia moves back under the femur, the posterior
cruciate ligament may be torn.
Ballotable
Patella (Major Knee Effusion)
1.
Ask the patient to lie supine on the exam table with leg muscles
relaxed.
2. Press the patella downward and quickly release it.
3. If the patella visibly rebounds, a large knee effusion
(excess fluid in the knee) is present.
Milking
the Knee (Minor Knee Effusion)
1.
Ask the patient to lie supine on the exam table with leg muscles
relaxed.
2. Compress the suprapatellar pouch with your thumb, palm,
and index finger.
3. "Milk" downward and laterally so that any excess
fluid collects on the medial side.
4. Tap gently over the collected fluid and observe the effect
on the lateral side, or ballot the
patella as outlined above.
5. A fullness on the lateral side indicates that a small knee
effusion is present.
Back
Straight
Leg Raising (L5/S1 Nerve Roots)
1.
Ask the patient to lie supine on the exam table with knees
straight.
2. Grasp the leg near the heel and raise the leg slowly toward
the ceiling.
3. Pain in an L5 or S1 distribution suggests nerve root compression
or tension (radicular pain).
4. Dorsiflex the foot while maintaining the raised position
of the leg.
5. Increased pain strengthens the likelihood of a nerve root
problem.
6. Repeat the process with the opposite leg.
7. Increased pain on the opposite side indicates that a nerve
root problem is almost certain
FABER
Test (Hips/Sacroiliac Joints)
FABER
stands for Flexion, Abduction, and External Rotation of the
hip.
This
test is used to distinguish hip or sacroiliac joint pathology
from spine problems.
1.
Ask the patient to lie supine on the exam table.
2. Place the foot of the effected side on the opposite knee
(this flexes, abducts, and externally
rotates the hip).
3. Pain in the groin area indicates a problem with the hip
and not the spine.
4. Press down gently but firmly on the flexed knee and the
opposite anterior superior iliac crest.
5. Pain in the sacroiliac area indicates a problem with the
sacroiliac joints.
Notes
1.
For more information refer to A Guide to Physical Examination
and History Taking, Seventh Edition
by Barbara Bates, published by Lippincott
in 1999. Additional reference is made to Physical Examination
of the Spine and Extremities, by Stanley
Hoppenfeld published in 1976 by Appleton
Century Crofts.
2. It is wise to start palpation some distance from a suspected
tender area. Proceed slowly and minimize
palpation of tender spots once they are
identified. Examine at least one joint above and below an
injured area.
3. Joint motion may be limited by any combination of pain,
weakness, mechanical block within
the joint, deformity, contracture of the soft tissues
(muscles, ligaments, musculo-tendinous structures, joint capsule,
etc), and patient factors. Joint motion may be increased by
instability, ligamentous laxity and/or
deformity.
4. Normally the ratio of glenohumeral to scapular movement
is 2:1. If the range of motion of
the glenohumeral joint is reduced, the patient will increase
the amount of scapular movement to compensate and the ratio
will change.
5. Snuffbox Tenderness is more sensitive than an x-rays for
identifying scaphoid fractures. Tenderness
in this area after an injury should be treated
as a fracture even if the x-rays are negative.
6. Holding the knee in flexion helps isolate the collateral
ligaments. Secondary stabilizers (anterior
cruciate ligament, joint capsule) come into
play when the knee is in full extension. If the knee "opens
up" in full extension, these
secondary structures may also be damaged.
7. The Lachman Test is used by athletic trainers on the field
to check for cruciate ligament injury.
It is very accurate and can be done on an acutely
injured knee (when the patient cannot tolerate bending the
knee for a drawer test).
8. The Drawer Test is the "classic" technique to
check for cruciate ligament injury.
It is less accurate and cannot be done on an acutely injured
knee (when the patient cannot tolerate bending). The Lachman
Test is preferred in most situations.
9. The FABER Test is also known as the Fabere or Patrick test.
Examination
of the Chest and Lungs
Equipment
Needed
- A
Stethoscope
- A
Peak Flow Meter
A
chest examination. This involves inspection, palpation, percussion,
and auscultation (IPPA):
General
Considerations
- The
patient must be properly undressed and gowned for this examination.
- Ideally
the patient should be sitting on the end of an exam table.
- The
examination room must be quiet to perform adequate percussion
and auscultation.
- Observe
the patient for general signs of respiratory disease (finger
clubbing, cyanosis, air hunger, etc.).
- Try
to visualize the underlying anatomy as you examine the patient.
Inspection
Observe
the rate, rhythm, depth, and effort of breathing. Note whether
the expiratory phase is prolonged.
1. Listen for obvious abnormal sounds with breathing such
as wheezes.
2. Observe for retractions and use of accessory muscles (sternomastoids,
abdominals).
3. Observe the chest for asymmetry, deformity, or increased
anterior-
posterior (AP) diameter.
4. Confirm that the trachea is near the midline.
The
thoracic cage provides the framework for the mechanics of
ventilation. The normal adult thorax has an anterior-posterior
(A-P) diameter less than the transverse diameter. Abnormalities
of the ribs, spine, clavicles or sternum may seriously affect
the ability of the respiratory muscles to cause ventilation
For
example, the A-P diameter gradually increases with age, but
prematurely increases in patients with COPD. The typical COPD
patients chest has an increase in anterior-posterior
diameter, referred to as a "barrel chest". A barrel
chest results in a mechanical disadvantage to breathing. The
chronic air trapping characteristic of the COPD process usually
causes this configuration. The diaphragm is low and flat and
the anterior chest elevated. Ventilation now occurs only with
great effort and increased oxygen consumption.
There
can also be disfiguration of the chest in other ways, such
as kyphoscoliosis, scoliosis, or restricted lung expansion.
These restrictive defects such as kyphosis or scoliosis reduce
the patients ability to take a deep breath and to cough.
This puts these patients at high risk after major surgery.
Acute injuries to the chest wall that cause multiple rib fractures
may cause flail chest and paradoxical breathing. Ventilatory
failure may eventually occur without proper support.
Upon
inspection the caregiver should note chest configuration,
scars, trauma, movement, and the presence of chest tubes or
incisions. If there are any visible chest scars, the caregivers
should ask the patient about them. These are usually due to
some past trauma or surgery. Caregivers should make note of
any splinting of the chest caused by pain, and attempt to
visualize any trauma to the lungs that may lie beneath the
chests scars or incisions. Often, patients have experienced
contusion pneumonia with hemorrhage beneath. Past chest trauma
is also frequently accompanied by significant fibrosis of
the lung in adjoining areas. Insertion of chest tubes in the
lower chest to drain fluid from the pleural space, and those
placed high to evacuate air are frequently the cause of the
visible acute trauma.
Caregivers
should notice the patients use of accessory muscles
during ventilation, and pay attention to the synchrony or
paradoxical motions of ventilation and count the ventilatory
rate. By placing his hands on the patients lower chest,
with thumbs just barely touching in the back, the caregiver
can evaluate chest movements. The caregiver should then ask
the patient to take a deep breath, and then observe if the
thumbs move apart symmetrically. If not, it may be that the
presence of unilateral disease is causing one side to move
more than the other. Atelectasis, pneumothorax, and pleural
effusions are all conditions that can cause unilateral movement.
In
COPD patients due to air trapping, there is very little observable
chest movement. There is also little chest movement seen in
patients with restrictive disease. Crackling sounds heard
around surgical incision sites when the caregiver's hands
are placed on the skin can be suggestive of subcutaneous emphysema.
It
should be noted that inspection for the presence of respiratory
disease requires inspection of more than the thorax. The caregiver
should inspect the extremities for digital clubbing and cyanosis.
The neck should also be assessed for evidence of jugular venous
distension (JVD). JVD occurs when the right side of the heart
fails due to chronic elevation of pulmonary vascular resistance
(PVR). Hypoxemia increases PVR, and over a long period of
time the right ventricle cannot effectively work against this
added resistance, and ventricular failure results.
Palpation
1.
Identify any areas of tenderness or deformity by palpating
the ribs and sternum.
2. Assess expansion and symmetry of the chest by placing your
hands on the patient's back, thumbs
together at the midline, and asking him to breath
deeply.
3. Check for tactile fremitus.
Palpation involves touching the chest
wall in order to evaluate underlying
structure and function, and is used to confirm or rule out
suspected problems identified by the
interview, history, and initial inspection.
Palpation is generally performed to:
- evaluate
vocal fremitus
- estimate
thoracic expansion
- assess
the chests skin and subcutaneous tissues
The
term fremitus refers to the vibrations that are transmitted
through lung tissues and the chest wall whenever a vocal sound
is made. When these vibrations are felt on the chest wall
during palpation, they are called tactile fremitus. A comparison
of these vibrations between both lungs is performed. There
are differences in fremitus between men and women, and fat
and thin people, but a comparison of fremitus within an individual
is what needs to be noted.
To
palpate for fremitus, the caregiver places the palmar aspect
of the fingers or the ulnar aspect of the hand against the
chest and has the patient repeat the number "99."
All areas of the chest should be compared, both front and
back. Fremitus should be equal over all areas of normal lung
tissue except over the right upper lobe, where it increases
because the bronchus is closer to the chest wall. Tactile
fremitus increases in intensity whenever the density of lung
tissue increases, such as in consolidation or fibrosis, and
will decrease when a lung space is occupied with an increase
of fluid or air (e.g., pleural effusion, pneumothorax and
emphysema). The causes of abnormal tactile fremitus include:
Increased:
o
Pneumonia
o Lung tumor or mass
o Pulmonary fibrosis
o Atelectasis
Decreased
Unilateral
- Bronchial
obstruction with mucus plug or foreign object
- Pleural
effusion
- Pneumothorax
Diffuse
- Muscular
or obese chest wall
- Chronic
obstructive lung disease
Palpable
vibrations referred to as bronchial fremitus may be produced
by the passage of air through airways containing thick secretions.
Bronchial fremitus often identified during inhalation and
exhalation may clear if the patient produces an effective
cough. It is frequently associated with a low-pitched, coarse
sound that can be heard without using a stethoscope.
Thoracic
expansion
The
patients chest wall normally expands symmetrically during
deep inhalations, and the caregiver can evaluate the expansion
on both the anterior and posterior chest. The caregiver first
places hands over the anterolateral chest, extending the thumbs
along the costal margin toward the xiphoid. To evaluate it
posteriorally, the hands are placed over the posterolateral
chest, with thumbs joining at approximately T8. Instruct the
patient to exhale slowly and completely. Once completed, the
caregiver's fingertips are secured against the sides of the
patients chest, extending the thumbs toward the midline
until their tips meet at the midline. The patient is then
instructed to take a full deep breath. The CAREGIVER takes
note of the distance each thumb moves away from the midline.
Normal movement is about 3-5 cm for each thumb.
 |
Bilateral
reduction in chest expansion can usually be seen in
patients with diseases affecting the expansion of both
lungs. Unilateral reduction in expansion is indicative
of a respiratory disease that impedes expansion of one
lung, such as lobar consolidation, pleural effusion,
atelectasis, or pneumothorax.
|
The
skin and subcutaneous tissues of the chest wall should
be palpated to ascertain the general temperature and condition
of the skin. When there is air leaking from the lung into
the subcutaneous tissues, fine bubbles create crackling sounds
and sensations when being palpated. This condition is called
subcutaneous emphysema, and the sensation produced
during palpation is referred to as crepitus.
Percussion
Proper
Technique
1.
Hyperextend the middle finger of one hand and place the distal
interphalangeal joint firmly
against the patient's chest.
2.
With the end (not the pad) of the opposite middle finger,
use a quick flick of the wrist to
strike the first finger.
3.
Categorize what you hear as normal, dull, or hyperresonant.
4.
Practice your technique until you can consistently produce
a "normal" percussion note
on your (presumably normal) partner before you work with
patients.
The
act of tapping on a surface in order to evaluate the underlying
sound is called percussion, and percussion of the patients
chest wall creates a sound and palpable vibration that is
useful in evaluating underlying lung tissue. The vibration
created by percussion penetrates the lung to a depth of about
5-7 cm below the chest wall.
To
perform chest percussion, the middle finger of the left hand
is placed firmly on the area to be percussed. The back of
the middle phalanx is then struck with the tip of the middle
finger of the right hand. Deliver the stroke from the wrist
and finger joints, bending the percussing finger so its terminal
phalanx is at right angles to the metacarpal bones when the
blow is delivered; and so strikes the pleximeter finger in
a perpendicular way.
 |
Percussion
over normal lung fields produces a low-pitch sound that
is easy to hear (referred to as normal resonance). Resonance
is said to be increased when the percussion note is louder
and lower in pitch. Percussion may also produce a high-pitched,
short in duration sound that is dull or flat, just the
opposite of resonance. |
| The
percussion of the chest alone has little clinical implication;
however, when it is considered with other findings, it
can yield essential information. |
Posterior
Chest
 |
1.
Percuss from side to side and top to bottom using
the pattern shown in the illustration. Omit
the areas covered by the scapulae.
2. Compare one side to the other looking for asymmetry.
3. Note the location and quality of the percussion
sounds you hear.
4. Find the level of the diaphragmatic dullness on
both sides.
|
Diaphragmatic
Excursion
5. Find the level of the diaphragmatic dullness on both sides.
6. Ask the patient to inspire deeply.
7. The level of dullness (diaphragmatic excursion) should
go down 3-5cm symmetrically.
Anterior
Chest
1.
Percuss from side to side and top to bottom using the pattern
shown in the illustration.
2. Compare one side to the other looking for asymmetry.
3. Note the location and quality of the percussion sounds
you hear.
Interpretation
|
Percussion
Notes and Their Meaning
|
| Flat
or Dull |
Pleural
Effusion or Lobar Pneumonia |
| Normal |
Healthy
Lung or Bronchitis |
| Hyperresonant |
Emphysema
or Pneumothorax |
|
Chest
percussion is generally performed to evaluate the extent of
diaphragmatic excursion and air-fluid levels. The note heard
on percussion becomes more resonant as the diaphragm descends
and the lungs fill with air. When the sound changes to a dull
note, it indicates the limit of diaphragmatic descent. The
less resonant the percussion notes are indicative of tissues
that are denser. As a result, air naturally produces the most
resonant sounds, such as is heard over a pneumothorax. Normal
lung tissue produces duller sounds, with accumulation of fluids
producing even duller sounds. The dullest of all sounds are
heard when percussing over bone structure.
Abnormalities
that increase lung tissue density, such as atelectasis or
pneumonic consolidation, result in a loss of resonance and
a dull percussion note above the affected area.
Auscultation
Use
the diaphragm of the stethoscope to auscultate breath sounds.
Posterior Chest
1. Auscultate from side to side and top to bottom using the
pattern shown in the illustration.
Omit the areas covered by the scapulae.
2. Compare one side to the other looking for asymmetry.
3. Note the location and quality of the sounds you hear.
Anterior
Chest
1.
Auscultate from side to side and top to bottom using the pattern
shown in the illustration.
2. Compare one side to the other looking for asymmetry.
3. Note the location and quality of the sounds you hear.
The next step in evaluating the patients
chest auscultation is the process
of listening for bodily sounds. Chest auscultation involves
the use of a stethoscope to enhance
transmission, and it takes place over the
thorax to identify normal or abnormal lung sounds.
The patient, who is being examined sitting upright in a relaxed
position, is instructed to breathe a bit more deeply than
usual through an open mouth. Their inhalation should be active,
and exhalation passive. The caregiver should proceed with
the auscultation in a systematic manner, examining all lobes
on the anterior, lateral, and posterior chest. Beginning at
the base, the caregiver should compare sides, and work toward
the lung apexes. At least one full ventilatory cycle should
be evaluated at each stethoscope position.
Correct
techniques for performing chest auscultation include:
- Placing
the stethoscopes bell or diaphragm directly against
the chest wall
-
Keeping the stethoscopes tubing free from contact
with any objects during auscultation
- Turning
off any radio or television in the room
- If
patients chest hair is thick, wetting it prior to
auscultation
- Asking
alert patients to sit up; rolling comatose patients on side
to auscultate posterior lobes
The
most common errors to be avoided during chest auscultation
include:
- Listening
to breath sounds through the patients bed clothes
- Attempting
to auscultate in a noisy room
- Permitting
the stethoscopes tubing to rub against bed rails or
patients clothing
- Misinterpreting
chest hair sounds as adventitious lung sounds
-
Auscultating only the areas that are convenient to get to
Numerous types of breath sounds can be heard when auscultating
over the lungs. Normal breath sounds are generated mainly
by the turbulence of air in the larger airways. The turbulent
flow creates audible vibrations, producing sounds that are
transmitted through the lung and chest wall. Normal lung
tissue acts as a filter that primarily passes muffled low-frequency
sounds. Normal breath sounds are "breezy" in quality,
heard mainly on inspiration, and somewhat faint.
Bronchial
breath sounds are considered to be abnormal sounds when they
are heard over peripheral lung regions. When lung tissue becomes
consolidated and increases in density, as it does in pneumonia
or atelectasis, the filtering effect is lost. Diminished sounds
occur when the intensity of the sound at the site of the larger
airways is reduced, or when sound transmission through the
lung or chest wall is decreased. The intensity of the sound
is reduced with shallow or slow breathing patterns. Chronic
airflow obstruction markedly reduces sound intensity throughout
all lung fields. Shallow breathing patterns also contribute
to decreased breath sounds in COPD patients.
As
mentioned above, some of the abnormal breath sounds that may
be heard by the caregiver during chest auscultation include:
o
Wheezes and rhonchi--Wheezes and some rhonchi are vibrations
caused by air flowing rapidly through a narrowed airway. Bronchospasm,
mucosal edema, or foreign object can constrict the airways
diameter. The pitch of the wheeze is related to the extent
of airway narrowing. The greater the narrowing, the higher
the pitch. Low-pitched, continuous rhonchi are frequently
associated with the excessive presence of secretions in the
airways. Some findings regarding the significance of expiratory
wheezing include:
1.
patients with chronic airway obstruction who wheeze are more
likely to show improvement after bronchodilator
administration than those who dont
wheeze;
2. less intensive wheezing is associated with a wide range
of obstructive defects, while more
intensive wheezing indicates moderate to severe airway
obstruction;
3. polyphonic wheezing (multiple notes) suggests many obstructed
airways, such as with asthma.
o
Crackles (rales)--Crackles are discontinuous, bubbling
or popping sounds produced when airways pop open as air travels
through fluid or small airways. Crackles can also be heard
in patients without excess secretions. These occur when collapsed
airways pop open during inspiration. While inspiratory crackles
are considered abnormal, they can occur in normal individuals
in certain situations. Crackles produced by the sudden opening
of peripheral airways are called late-inspiratory crackles,
and are most common in patients with respiratory diseases
that reduce lung volume, including pneumonia, pulmonary edema,
fibrosis, and atelectasis.
o
Voice sounds--Vocal resonance should be assessed if
chest inspection, palpation, percussion, or auscultation suggests
any abnormalities. The patient is instructed to repeat the
numbers "1, 2, 3" or "99" while the examiner
uses a stethoscope to listen over the sides of the chest wall.
The three types of vocal sounds heard are:
o
Bronchophony--an increase in intensity and clarity
of vocal resonance; is indicative of increased
lung tissue density.
o Epophony--increased intensity of voice, with a nasal
or bleating character; indicative of a compressed
lung above a pleural effusion.
o Whispering pectoriloquy--high-frequency vibrations
created when patients are asked to whisper
"1, 2, 3) while the CAREGIVER listens over
the lung periphery with a stethoscope; helpful in finding
small or patchy areas of lung consolidation.
o Pleural friction rub--creaking or grating sound occurring
when pleural surfaces are inflamed, and
the roughened edges rub together during breathing;
found in patients with pleurisy.
Interpretation
Breath
sounds are produced by turbulent airflow. They are categorized
by the size of the airways that transmit them to the chest
wall (and your stethoscope). The general rule is, the larger
the airway, the louder and higher pitched the sound. Vesicular
breath sounds are low pitched and normally heard over most
lung fields. Tracheal breath sounds are heard over the trachea.
Bronchovesicular and bronchial sounds are heard in between.
Inspiration is normally longer than expiration (I > E).
Breath
sounds are decreased when normal lung is displaced
by air (emphysema or pneumothorax) or fluid (pleural effusion).
Breath sounds shift from vesicular to bronchial when
there is fluid in the lung itself (pneumonia). Extra sounds
that originate in the lungs and airways are referred to as
"adventitious" and are always abnormal (but not
always significant). (See Table)
|
Adventitious
(Extra) Lung Sounds
|
| Crackles |
These
are high-pitched, discontinuous sounds similar
to the sound produced by rubbing your hair between
your fingers. (Also known as Rales)
|
| Wheezes |
These
are generally high pitched and "musical"
in quality. Stridor is an inspiratory wheeze associated
with upper airway obstruction (croup).
|
| Rhonchi |
These
often have a "snoring" or "gurgling"
quality. Any extra sound that is not a crackle
or a wheeze is probably a rhonchus.
|
|

Special Tests
Peak
Flow Monitoring
Peak
flow meters are inexpensive, hand-held devices used to monitor
pulmonary function in patients with asthma. The peak flow
roughly correlates with the FEV1.
1.
Ask the patient to take a deep breath.
2. Then ask them to exhale as fast as they can through
the peak flow meter.
3. Repeat the measurement 3 times and report the average.
Voice
Transmission Tests
These
tests are only used in special situations. This part of the
physical exam has largely been replaced by the chest x-ray.
All these tests become abnormal when the lungs become filled
with fluid (referred to as consolidation).
Tactile
Fremitus
1.
Ask the patient to say "ninety-nine" several times
in a normal voice.
2. Palpate using the ball of your hand.
3. You should feel the vibrations transmitted through the
airways to the lung.
Increased
tactile fremitus suggests consolidation of the underlying
lung tissues. Bronchophony
1.
Ask the patient to say "ninety-nine" several times
in a normal voice.
2. Auscultate several symmetrical areas over each lung.
3. The sounds you hear should be muffled and indistinct. Louder,
clearer sounds are called bronchophony.
Whispered
Pectoriloquy
1.
Ask the patient to whisper "ninety-nine" several
times.
2. Auscultate several symmetrical areas over each lung.
3. You should hear only faint sounds or nothing at all.
4. If you hear the sounds clearly this is referred to as whispered
pectoriloquy.
Egophony
1.
Ask the patient to say "ee" continuously.
2. Auscultate several symmetrical areas over each lung.
3. You should hear a muffled "ee" sound. If you
hear an "ay" sound this is referred
to as "E -> A" or egophony.
Notes
1.
For more information refer to A Guide to Physical Examination
and History Taking, Seventh Edition
by Barbara Bates, published by Lippincott
in 1999.
2. A prolonged expiratory phase (E > I) indicates airway
narrowing, as in asthma.
3. AP diameter increases somewhat with age; however, a round
or "barrel" chest is often
a sign of advanced emphysema.
4. The trachea will deviate to one side in cases of tension
pneumothorax.
5. Additional Testing - Decreased or asymmetric diaphragmatic
excursion may indicate paralysis or
emphysema
6. It has been said that "a peak flow meter is to asthma
as a thermometer is to fever."
Peak flow measurements are used to gauge severity
of asthma attacks and track the disease over time. Ideally
new readings are compared to the patient's
current "personal best." Readings
less than 80% of "best" may indicate a need for
additional therapy. Readings less
than 50% may indicate an emergency situation.
7. Increased fremitus indicates fluid in the lung.
Decreased fremitus indicates sound
transmission obstructed by chronic obstructive pulmonary
disease (COPD), fluid outside the lung (pleural effusion),
air outside the lung (pneumothorax),
etc. #Whispered pectoriloquy is right
up there with borborygmi on this authors list of favorite
medical terms.
Cardiovascular
Examination
Equipment
Needed
- A
Double-Headed, Double-Lumen Stethoscope
- A
Blood Pressure Cuff
- A
Moveable Light Source or Pen Light
General
Considerations
- The
patient must be properly undressed and in a gown for this
examination.
- The
examination room must be quiet to perform adequate auscultation.
- Observe
the patient for general signs of cardiovascular disease
(finger clubbing, cyanosis, edema, etc.).
Arterial
Pulses
Rate
and Rhythm
1.
Compress the radial artery with your index and middle fingers.
2. Note whether the pulse is regular or irregular.
3. Count the pulse for 15 seconds and multiply by 4.
4. Count for a full minute if the pulse is irregular.
5. Record the rate and rhythm.
|
Pulse
Classification in Adults (At Rest)
|
|
Normal
|
Bradycardia
|
Tachycardia
|
| 60
to 100 bpm |
less
than 60 bpm |
more
than 100 |
|
Regular
|
Regularly
Irregular
|
Irregularly
Irregular
|
| Evenly
spaced beats, may vary slightly with respiration |
Regular
pattern overall with "skipped" beats |
Chaotic,
no real pattern, very difficult to measure rate
accurately |
|
Amplitude
and Contour
1. Observe for carotid pulsations.
2. Place your fingers behind the patient's neck and compress
the carotid artery on one side with
your thumb at or below the level of the cricoid cartilage.
Press firmly but not to the point of discomfort.
3. Assess the following:
o The amplitude of the pulse.
o The contour of the pulse wave.
o Variations in amplitude from beat
to beat or with respiration.
4. Repeat on the opposite side.
Auscultation
for Bruits
If
the patient is late middle-aged or older, you should auscultate
for bruits. A bruit is often, but not always, a sign of arterial
narrowing and risk of a stroke.
1. Place the bell of the stethoscope over each carotid artery
in turn. You may use the diaphragm
if the patient's neck is highly contoured.
2. Ask the patient to stop breathing momentarily.
3. Listen for a blowing or rushing sound--a bruit. Do not
be confused by heart sounds or murmurs
transmitted from the chest.
Blood
Pressure
The
patient should not have eaten, smoked, taken caffeine, or
engaged in vigorous exercise within the last 30 minutes. The
room should be quiet and the patient comfortable.
1.
Position the patient's arm so the anticubital fold is level
with the heart.
2. Center the bladder of the cuff over the brachial artery
approximately 2 cm above the anticubital
fold. Proper cuff size is essential to obtain an
accurate reading. Be sure the index line falls between the
size marks when you apply the cuff.
Position the patient's arm so it is slightly
flexed at the elbow.
3. Palpate the radial pulse and inflate the cuff until the
pulse disappears. This is a rough
estimate of the systolic pressure.
4. Place the stethoscope over the brachial artery.
5. Inflate the cuff 20 to 30 mmHg above the estimated systolic
pressure.
6. Release the pressure slowly, no greater than 5 mmHg per
second.
7. The level at which you consistently hear beats is the systolic
pressure.
8. Continue to lower the pressure until the sounds muffle
and disappear. This is the diastolic
pressure.
9. Record the blood pressure as systolic over diastolic (120/70).
10. Blood pressure should be taken in both arms on the first
encounter.
Auscultation
1.
Position the patient supine with the head of the table slightly
elevated.
2. Always examine from the patient's right side. A quiet room
is essential.
3. Listen with the diaphragm at the right 2nd interspace near
the sternum (aortic area).
4. Listen with the diaphragm at the left 2nd interspace near
the sternum (pulmonic area).
5. Listen with the diaphragm at the left 3rd, 4th, and 5th
interspaces near the sternum (tricuspid
area).
6. Listen with the diaphragm at the apex (mitral area).
7. Listen with the bell at the apex.
8. Listen with the bell at the left 4th and 5th interspace
near the sternum.
9. Have the patient roll on their left side.
o Listen with the bell at the apex.
o This position brings out S3 and
mitral murmurs.
10. Have the patient sit up, lean forward, and hold their
breath in exhalation.
o Listen with the diaphragm
at the left 3rd and 4th interspace near the
sternum.
o This position brings out aortic
murmurs.
11. Record S1, S2, (S3), (S4), as well as the grade and configuration
of any murmurs ("two over
six" or "2/6", "pansystolic" or "crescendo").
Interpretation
|
Murmur
Grades
|
|
Grade
|
Volume
|
Thrill
|
|
1/6
|
very faint, only heard with optimal conditions |
no
|
|
2/6
|
loud enough to be obvious |
no
|
|
3/6
|
louder than grade 2 |
no
|
|
4/6
|
louder than grade 3 |
yes
|
|
5/6
|
heard with the stethoscope partially off the chest
|
yes
|
|
6/6
|
heard
with the stethoscope completely off the chest
|
yes
|
|
Notes
1.
For more information refer to A Guide to Physical Examination
and History Taking, Seventh Edition
by Barbara Bates, published by Lippincott
in 1999.
2. With an irregular pulse, the beats counted in any 30 second
period may not represent the overall
rate. The longer you measure, the more these
variations are averaged out.
3. Avoid compressing both sides at the same time. This could
cut off the blood supply to the brain
and cause syncope. Avoid compressing the carotid
sinus higher up in the neck. This could lead to bradycardia
and decreased blood pressure.
4. Bell or Diaphragm? - Even though Korotkoff sounds are low
frequency and should be heard better
with the bell, it is often difficult to apply the
bell properly to the anticubital fold. For this reason, it
is common practice to use the diaphragm
when taking the blood pressure.
5. Maximum Cuff Pressure - When the baseline blood pressure
is already known or hypertension is
not suspected, it is acceptable in adults to inflate
the cuff to 200 mmHg and go directly to auscultating the blood
pressure. Be aware that there could
be an auscultory gap (a silent interval
between the true systolic and diastolic pressures).
6. Systolic Pressure - In situations where auscultation is
not possible, you can determine systolic
blood pressure by palpation alone. Deflate the cuff
until you feel the radial or brachial pulse return. The pressure
by auscultation would be approximately
10 mmHg higher. Record the pressure
indicating it was taken by palpation (60/palp).
7. Diastolic Pressure - If there is more than 10 mmHg difference
between the muffling and the disappearance
of the sounds, record all three numbers
(120/80/45).
8. Pressure Differences - If there is more than 10 mmHg difference
between the two arms, use the arm
with the higher reading for subsequent
measurements.
9. Sternal Angle - The sternal angle is taken to be 5cm above
the right atrium. A jugular pulse
10cm above the sternal angle equates to a central
venous pressure of 15cm of water.
10. Left Sternal Border - The left 3rd, 4th, and 5th interspaces
are considered the tricuspid
area and are referred to as the Lower Left
Sternal Border or LLSB.
Examination of the Head and Neck
Equipment
Needed
- An
Otoscope
- Tongue
Blades
- Cotton
Tipped Applicators
- Latex
Gloves
General Considerations
The head and neck exam is not a single, fixed sequence.
Different portions are included depending on the examiner
and the situation.
Head
1.
Look for scars, lumps, rashes, hair loss, or other lesions.
2. Look for facial asymmetry, involuntary movements, or edema.
3. Palpate to identify any areas of tenderness or deformity.
Ears
1.
Inspect the auricles and move them around gently. Ask the
patient if this is painful.
2. Palpate the mastoid process for tenderness or deformity.
3. Hold the otoscope with your thumb and fingers so that the
ulnar aspect of your hand makes contact
with the patient.
4. Pull the ear upward and backward to straighten the canal.
5. Insert the otoscope to a point just beyond the protective
hairs in the ear canal. Use the largest
speculum that will fit comfortably.
6. Inspect the ear canal and middle ear structures noting
any redness, drainage, or deformity.
7. Insufflate the ear and watch for movement of the tympanic
membrane.
8. Repeat for the other ear.
Nose
It
is often convenient to examine the nose immediately after
the ears using the same speculum.
1. Tilt the patient's head back slightly. Ask him to hold
his breath for the next few seconds.
2. Insert the otoscope into the nostril, avoiding contact
with the septum.
3. Inspect the visible nasal structures and note any swelling,
redness, drainage, or deformity.
4. Repeat for the other side.
Throat
It
is often convenient to examine the throat using the otoscope
with the speculum removed.
1.
Ask the patient to open his mouth.
2. Using a wooden tongue blade and a good light source, inspect
the inside of the patients mouth
including the buccal folds and under the tongue.
Note any ulcers, white patches (leukoplakia), or other lesions.
3. If abnormalities are discovered, use a gloved finger to
palpate the anterior structures and
floor of the mouth.
4. Inspect the posterior oropharynx by depressing the tongue
and asking the patient to say "Ah."
Note any tonsillar enlargement, redness, or discharge.
Neck
1.
Inspect the neck for asymmetry, scars, or other lesions.
2. Palpate the neck to detect areas of tenderness, deformity,
or masses.
3. The musculoskeletal exam of the neck is covered elsewhere
in this CEU.
Lymph
Nodes
1.
Systematically palpate with the pads of your index and middle
fingers for the various lymph node
groups.
1. Preauricular - In front of the
ear
2. Postauricular - Behind the ear
3. Occipital - At the base of the
skull
4. Tonsillar - At the angle of the
jaw
5. Submandibular - Under the jaw on
the side
6. Submental - Under the jaw in the
midline
7. Superficial (Anterior) Cervical
- Over and in front of the sternomastoid
muscle
8. Supraclavicular - In the angle
of the sternomastoid and the clavicle
2.
The deep cervical chain of lymph nodes lies
below the sternomastoid and cannot
be palpated without getting underneath the muscle:
 |
1.
Inform the patient that this procedure will
cause some discomfort.
2. Hook your fingers under the anterior edge
of the sternomastoid muscle.
3. Ask the patient to bend his neck toward
the side you are examining.
4. Move the muscle backward and palpate for
the deep nodes underneath.
|
3. Note the size and location of any palpable nodes and whether
they were soft or hard, non-tender or tender, and mobile or
fixed.
Thyroid
Gland
1.
Inspect the neck looking for the thyroid gland. Note whether
it is visible and symmetrical. A visibly
enlarged thyroid gland is called a goiter.
2. Move to a position behind the patient.
3. Identify the cricoid cartilage with the fingers of both
hands.
4. Move downward two or three tracheal rings while palpating
for the isthmus.
5. Move laterally from the midline while palpating for the
lobes of the thyroid.
6. Note the size, symmetry, and position of the lobes, as
well as the presence of any nodules.
The normal gland is often not palpable.
Special
Tests
Facial
Tenderness
1.
Ask the patient to tell you if these maneuvers cause excessive
discomfort or pain.
2. Press upward under both eyebrows with your thumbs.
3. Press upward under both maxillas with your thumbs.
4. Excessive discomfort on one side or significant pain suggests
sinusitis.
Sinus
Transillumination
1.
Darken the room as much as possible.
2. Place a bright otoscope or other point light source on
the maxilla.
3. Ask the patient to open his mouth and look for an orange
glow on the hard palate.
4. A decreased or absent glow suggests that the sinus is filled
with something other than air.
Temporomandibular
Joint
1.
Place the tips of your index fingers directly in front of
the tragus of each ear.
2. Ask the patient to open and close his mouth.
3. Note any decreased range of motion, tenderness, or swelling.
Notes
1.
Page numbers refer to Barbara Bates' A Guide to Physical Examination
and History Taking, Seventh Edition
, published by Lippincott in 1999.
2. The line of hairs in the external ear is a good approximation
of where the bony canal begins. Inserting
the speculum beyond this point can be
very painful.
Insufflation
means to change the pressure in the outer ear. The tympanic
membrane normally moves easily in response to this pressure
change. Lack of movement is a sign of negative pressure or
fluid in the middle ear. Bates refers to this procedure as
pneumatic otoscopy.
|
Examination
of the Eye
Equipment
Needed
- A
Snellen Eye Chart or Pocket Vision Card
- An
Ophthalmoscope
|
 |
Visual
Acuity
In
cases of eye pain, injury, or visual loss, always check visual
acuity before proceeding with the rest of the exam or putting
medications in your patients eyes.
1.
Allow the patient to use his glasses or contact lens if available.
You are interested in the patient's
best-corrected vision.
2. Position the patient 20 feet in front of the Snellen eye
chart (or hold a Rosenbaum pocket
card at a 14 inch "reading" distance).
3. Have the patient cover one eye at a time with a card.
4. Ask the patient to read progressively smaller letters until
he can go no further.
5. Record the smallest line the patient read successfully
(20/20, 20/30, etc.)
6. Repeat with the other eye.
7. Unexpected/unexplained loss of acuity is a sign of serious
ocular pathology.
Inspection
 |
1.
Observe the patient for ptosis, exophthalmos, lesions,
deformities, or asymmetry.
2. Ask the patient to look up and pull down both lower
eyelids to inspect the conjunctiva
and sclera.
3. Next spread each eye open with your thumb and index
finger. Ask the patient to look
to each side and downward to expose
the entire bulbar surface. |
4.
Note any discoloration, redness, discharge, or lesions.
Note any deformity of the iris
or lesion of the cornea.
5. If you suspect the patient has conjunctivitis, be sure
to wash your hands
immediately. Viral conjunctivitis is highly contagious
- protect yourself! |
Visual
Fields
Screen
Visual Fields by Confrontation
1. Stand two feet in front of the patient and have him look
into your eyes.
2. Hold your hands to the side halfway between you and the
patient.
3. Wiggle the fingers on one hand.
4. Ask the patient to indicate on which side he sees your
fingers move.
5. Repeat two or three times to test both temporal fields.
6. If an abnormality is suspected, test the four quadrants
of each eye while asking the patient
to cover the opposite eye with a card.
Extraocular
Muscles
Corneal
Reflections
1.
Shine a light from directly in front of the patient.
2. The corneal reflections should be centered over the pupils.
3. Asymmetry suggests extraocular muscle pathology.
Extraocular
Movement
1.
Stand or sit 3 to 6 feet in front of the patient.
2. Ask the patient to follow your finger with his eyes without
moving his head.
3. Check gaze in the six cardinal directions using a cross
or "H" pattern.
4. Check convergence by moving your finger toward the bridge
of the patient's nose.
Pupillary
Reactions
Light
1.
Dim the room lights as necessary.
2. Ask the patient to look into the distance.
3. Shine a bright light obliquely into each pupil in turn.
4. Look for both the direct (same eye) and consensual (other
eye) reactions.
5. Record pupil size in mm and any asymmetry or irregularity.
Accommodation
If
the pupillary reactions to light are diminished or absent,
check the reaction to accommodation (near reaction):
1.
Hold your finger about 10cm from the patient's nose.
2. Ask him to alternate looking into the distance and at your
finger.
3. Observe the pupillary response in each eye.
Ophthalmoscopic
Exam
|


|
1.
Darken the room as much as possible.
2. Adjust the ophthalmoscope so that the light
is no brighter than necessary. Adjust
the aperture to a plain white circle.
Set the diopter dial to zero unless you
have determined a better setting for
your eyes.
3.
Use your left hand and left eye to examine
the patient's left eye. Use your right
hand and right eye to examine the patient's
right eye. Place your free hand on
the patient's shoulder for better control.
4. Ask the patient to stare at a point on the
wall or the corner of the room.
5. Look through the ophthalmoscope and shine
the light into the patient's eye from
about two feet away. You should see
the retina as a "red reflex." Follow
the
red color to move within a few inches
of the patient's eye.
|
|
|
6.
Adjust the diopter dial to bring the retina into focus.
Find a blood vessel and follow
it to the optic disk. Use this as a point of reference.
7. Inspect outward from the optic disk in at least four
quadrants and note any abnormalities.
8. Move nasally from the disk to observe the macula.
9. Repeat for the other eye.
|
|
 Special Tests
Upper
Eyelid Eversion
This
procedure is performed when a foreign body is suspected.
1. Ask the patient to look down.
2. Gently grasp the patient's upper eyelashes and pull
them out and down.
3. Place the shaft of an applicator or tongue blade
about1 cm from the lid margin.
4. Pull the lid upward using the applicator as a fulcrum
to turn the lid "inside
out." Do not press down on the eye itself.
5. Pin the eyelid in this position by pressing the lashes
against the eyebrow while you
examine the palpebral conjunctiva.
6. Ask the patient to blink several times to return
the lid to normal.
|
Notes
1.
Visual acuity is reported as a pair of numbers (20/20) where
the first number is how far the patient
is from the chart and the second number is
the distance from which the "normal" eye can read
a line of letters. For example, 20/40
means that at 20 feet the patient can only read letters
a "normal" person can read from twice that distance.
2. For more information refer to A Guide to Physical Examination
and History Taking, Seventh Edition
by Barbara Bates, published by Lippincott
in 1999.
3. You may, instead of wiggling a finger, raise one or two
fingers (unilaterally or bilaterally)
and have the patient state how many fingers (total,
both sides) he sees. To test for neglect, on some trials wiggle
your right and left fingers simultaneously.
The patient should see movement in
both hands.
4. PERRLA is a common abbreviation that stands for "Pupils
Equal Round Reactive to Light and
Accommodation." The use of this term is so routine
that it is often used incorrectly. If you did not specifically
check the accommodation reaction use
the term PERRL. Pupils with a diminished
response to light but a normal response to accommodation (Argyll-Robertson
Pupils) are a sign of neurosyphilis.
5. Diopters are used to measure the power of a lens. The ophthalmoscope
actually has a series of small lens
of different strengths on a wheel (positive
diopters are labeled in green, negative in red). When you
focus on the retina you "dial-in"
the correct number of diopters to compensate
for both the patient's and your own vision. For example, if
both you and your patient wear glasses
with -2 diopter correction you should
expect to set the dial to -2 with your glasses on or -4 with
your glasses off.
Examination
of the Abdomen
Equipment
Needed
General
Considerations
 |
- The
patient should have an empty bladder.
- The
patient should be lying supine on the exam table and
appropriately draped.
- The
examination room must be quiet to perform adequate
auscultation and percussion.
- Watch
the patient's face for signs of discomfort during
the examination.
- Use
the appropriate terminology to locate your findings:
o Right Upper Quadrant (RUQ)
o Right Lower Quadrant (RLQ)
o Left Upper Quadrant (LUQ)
o Left Lower Quadrant (LLQ)
o Midline:
Epigastric
Periumbilical
Suprapubic
- Disorders
in the chest will often manifest with abdominal symptoms.
It is always wise to examine the chest when evaluating
an abdominal complaint.
- Consider
the inguinal/rectal examination in males. Consider
the pelvic/rectal examination in females
|
Inspection
1.
Look for scars, striae, hernias, vascular changes, lesions,
or rashes.
2. Look for movement associated with peristalsis or pulsations.
3. Note the abdominal contour. Is it flat, scaphoid, or protuberant?
Auscultation
1.
Place the diaphragm of your stethoscope lightly on the abdomen.
2. Listen for bowel sounds. Are they normal, increased, decreased,
or absent?
3. Listen for bruits over the renal arteries, iliac arteries,
and aorta.
Percussion
1.
Percuss in all four quadrants using proper technique.
2. Categorize what you hear as tympanitic or dull. Tympany
is normally present over most of the
abdomen in the supine position. Unusual dullness
may be a clue to an underlying abdominal mass.
 |
Liver
Span
1. Percuss downward from the chest in the right midclavicular
line until you detect the top edge of liver
dullness.
2. Percuss upward from the abdomen in the same line until
you detect the bottom edge of liver dullness.
3. Measure the liver span between these two points. This
measurement should be 6-12 cm in a normal adult.
|
|

|
Splenic
Dullness
1. Percuss the lowest costal interspace in
the left anterior axillary line. This area
is normally tympanitic.
2. Ask the patient to take a deep breath
and percuss this area again. Dullness
in this area is a sign of splenic
enlargement. |
|
Palpation
General
Palpation
1.
Begin with light palpation. At this point you are mostly looking
for areas of tenderness. The most
sensitive indicator of tenderness is the patient's
facial expression (so watch the patient's face, not your hands).
Voluntary or involuntary guarding may also be present.
2. Proceed to deep palpation after surveying the abdomen lightly.
Try to identify abdominal masses or
areas of deep tenderness.
Palpation of the Liver
Standard
Method
1.
Place your fingers just below the right costal margin and
press firmly.
2. Ask the patient to take a deep breath.
3. You may feel the edge of the liver press against your fingers.
Or it may slide under your hand as
the patient exhales. A normal liver is not tender.
Alternate
Method
This
method is useful when the patient is obese or when the examiner
is small compared to the patient.
1. Stand by the patient's chest.
2. "Hook" your fingers just below the costal margin
and press firmly.
3. Ask the patient to take a deep breath.
4. You may feel the edge of the liver press against your fingers.
Palpation
of the Aorta
1.
Press down deeply in the midline above the umbilicus.
2. The aortic pulsation is easily felt on most individuals.
3. A well defined, pulsatile mass, greater than 3 cm across,
suggests an aortic aneurysm.
Palpation
of the Spleen
1.
Use your left hand to lift the lower rib cage and flank.
2. Press down just below the left costal margin with your
right hand.
3. Ask the patient to take a deep breath.
4. The spleen is not normally palpable on most individuals.
Special
Tests
Rebound
Tenderness
This
is a test for peritoneal irritation.
1. Warn the patient what you are about to do.
2. Press deeply on the abdomen with your hand.
3. After a moment, quickly release pressure.
4. If it hurts more when you release, the patient has rebound
tenderness.
Costovertebral
Tenderness
CVA
tenderness is often associated with renal disease.
1.
Warn the patient what you are about to do.
2. Have the patient sit up on the exam table.
3. Use the heel of your closed fist to strike the patient
firmly over the costovertebral angles.
4. Compare the left and right sides.
Shifting
Dullness
This
is a test for peritoneal fluid (ascites).
1. Percuss the patient's abdomen to outline areas of dullness
and tympany.
2. Have the patient roll away from you.
3. Percuss and again outline areas of dullness and tympany.
If the dullness has shifted to areas
of prior tympany, the patient may have excess
peritoneal fluid.
Psoas
Sign
This
is a test for appendicitis.
1. Place your hand above the patient's right knee.
2. Ask the patient to flex the right hip against resistance.
3. Increased abdominal pain indicates a positive psoas sign.
Obturator
Sign
This
is a test for appendicitis.
1. Raise the patient's right leg with the knee flexed.
2. Rotate the leg internally at the hip.
3. Increased abdominal pain indicates a positive obturator
sign.
Notes
1.
For more information refer to A Guide to Physical Examination
and History Taking, Seventh Edition
by Barbara Bates, published by Lippincott
in 1999.
2. Auscultation should be done prior to percussion and palpation
since bowel sounds may change with
manipulation. Since bowel sounds are transmitted
widely in the abdomen, auscultation of more than one quadrant
is not usually necessary. If you hear them, they are present,
period.
3. Tenderness felt in the RLQ when palpation is performed
on the left is called Rovsing's Sign
and suggests appendicitis. Rebound tenderness referred
from the left to the RLQ also suggests this disorder.
4. Small amounts of peritoneal fluid are not usually detectable
on physical exam.
Examination
of the Breast
Equipment
Needed
- None
- General
Considerations
- The
patient must be properly gowned for this examination. All
upper body clothing should be removed.
- Breast
tissue changes with age, pregnancy, and menstrual status.
- The
procedure described here can also be used for self-examination
using a mirror for inspection.
Inspection
 |
1.
Give a brief overview of the examination to patient.
2. Have the patient sit at end of exam table.
3. Ask the patient to remove gown to her waist, assist
only if needed.
4. Have the patient relax arms to her side.
5. Examine visually for following:
o
Approximate symmetry
o
Dimpling or retraction of skin
o
Swelling or discoloration
o
Orange peel effect on skin
o
Position of nipple |
6.
Observe the movement of breast tissue during the following
maneuvers:
o
Shrug shoulders with hands on hips
o
Slowly raise arms above head
o
Lean forward with hands on knees (large breasts only)
7. Have the patient replace the gown.
8. Reassure the patient. If the exam is normal so far,
say so. |
Palpation
1.
Have the patient lie supine on the exam table.
2. Ask the patient to remove the gown from one breast and
place her hand behind her head on
that side.
3. Begin to palpate at junction of clavicle and sternum using
the pads of the index, middle, and
ring fingers. If open sores or discharge are visible,
wear gloves.
4. Press breast tissue against the chest wall in small circular
motions. Use very light pressure to
assess superficial layer, moderate pressure for middle
layer and firm pressure for deep layers.
5. Palpate the breast in overlapping vertical strips. Continue
until you have covered the entire
breast including the axillary "tail."
6. Palpate around the areola and the depression under the
nipple. Press the nipple gently between
thumb and index finger and make note of any
discharge.
7. Lower the patient's arm and palpate for axillary lymph
nodes.
8. Have the patient replace the gown and repeat on the other
side.
9. Reassure the patient; discuss the results of the exam.
Notes
1.
For more information refer to A Guide to Physical Examination
and History Taking, Seventh Edition
by Barbara Bates, published by Lippincott
in 1999.
2. Bates refers to circular or clock face patterns. These
are considered to be inferior to the
"lawn mower" pattern of vertical strips and should
not be used.
Examination
of the Female Pelvis
Equipment
Needed
- Exam
Table Equipped with Stirrups
- Flexible
Light Source
- Vaginal
Specula in Various Sizes
- Warm
Running Water
- Lubricating
Jelly
General
Considerations
- The
patient must have an empty bladder.
- The
patient must be appropriately gowned and draped.
- Use
non-sterile gloves on both hands. Double-glove your dominant
hand if you intend to perform a rectal or rectovaginal exam.
- Properly
dispose of soiled equipment and supplies.
- Both
male and female examiners should be chaperoned by a female
assistant.
- Always
tell the patient what you are about to do before you do
it.
- The
breast exam is usually done just before routine pelvic exams.
Positioning
the Patient
1.
Start with the patient lying supine on the exam table with
the head elevated 30 to 45 degrees.
2. Assist the patient in placing her heels in the stirrups.
Adjust the angle and length to "fit"
the patient.
3. Have the patient slide her hips down until she contacts
your hand at the edge of the table.
4. Have the patient relax her knees outward just beyond the
angle of the stirrups.
External
Exam
1.
Uncover the vulva by moving the center of the drape away from
you. Try to avoid creating a "screen"
with the drape pulled tight between the
patient's knees.
2. Announce what you are going to do and then touch the patient
on the thigh with the back of your
hand before proceeding.
3. Inspect the outer genitalia for redness, swelling, lesions,
masses, or infestations.
4. Gently palpate the labia majora and minora.
5. Inspect the labia, the folds between them, and the clitoris.
6. Note any redness, swelling, lesions, or discharge.
7. Reassure the patient, if the exam is normal so far, say
so.
Internal
Exam
Speculum
Exam
 |
1.
Warm and lubricate the speculum by holding it under running
tap water.
2. Announce what you are going to do and then touch the
patient on the thigh with the speculum before proceeding.
3. Expose the introitus by spreading the labia from below
using the index and middle fingers of the non-dominant
hand (peace sign).
4. Insert the speculum at a 45 degree angle pointing slightly
downward. Avoid contact with the anterior structures.
|
5.
Once past the introitus, rotate the speculum to a horizontal
position and continue insertion until
the handle is almost flush with the perineum.
6. Open the "bills" of the speculum 2 or 3 cm using
the thumb lever. Position the bills
so that the cervix "falls" in between.
7. Secure the speculum by turning the thumb nut (metal speculum)
or clicking the ratchet mechanism
(plastic speculum). Do not move the speculum
while it is locked open.
8. Observe the cervix and vaginal walls for lesions or discharge.
Obtain specimens for culture and cytology
as indicated.
9. Withdraw the speculum slightly to clear the cervix. Loosen
the speculum and allow the "bills"
to fall together. Continue to withdraw while
rotating the speculum to 45 degrees. Again, avoid contact
with the anterior structures.
10. Replace the drape while you prepare for the rest of the
exam.
11. Reassure the patient, if the exam is
normal so far, say so.
Bimanual
Exam
1.
Apply a small amount of lubricant to the index and middle
fingers of your dominant hand.
2. Uncover the vulva and lower abdomen by moving the center
of the drape away from you.
3. Announce what you are going to do and then touch the patient
on the thigh with the back of your
hand before proceeding.
4. Spread the labia and insert your lubricated index and middle
fingers into the vagina. Avoid
contact with the anterior structures.
5. Place your other hand on the patient's lower abdomen.
6. Examine the cervix:
1. Palpate the cervix with your index
finger noting size, shape, and consistency.
2. Gently move the
cervix side to side between your fingers and note
mobility and tenderness.
3. Gently lift the
cervix forward and note mobility and tenderness.
7. Examine the anterior uterine fundus:
1. Continue to lift the cervix with
the vaginal hand.
2. Press downward with the abdominal
hand and palpate the uterus (if possible).
3. Note consistency and tenderness.
Attempt to estimate uterine size.
8. Examine the adnexal structures:
1. Pull back vaginal hand to clear
cervix.
2. Reposition vaginal hand into the
right fornix, palm up.
3. Sweep the right ovary downward
with the abdominal hand 3 or 4 cm medial
to the iliac crest.
4. Gently "trap"
the ovary between the fingers of both hands (if possible).
Note its size and shape along with any other palpable adnexal
structures.
5. Pull back and repeat on the left
side.
9. Replace the drape and assist the patient to remove her
feet from the stirrups and sit up.
10. Reassure the patient, if the exam is normal, say so.
11. Leave the room and allow the patient to dress before continuing
with the consultation.
Notes
1.
The rectal and rectovaginal exam are part of normal pelvic
examinations, but are not covered here..
2. For more information refer to A Guide to Physical Examination
and History
Taking, Seventh Edition by Barbara Bates, published by
Lippincott in 1999.
3. You will obtain a Papanicolaou (Pap) smear and other specimens
as
part of most pelvic exams. Pap smears are
analyzed for cervical cancer
cells by a cytology technician under the
supervision of a pathologist.
4. Tenderness with cervical motion is an important sign of
pelvic disease. You should both observe
the patient's face and ask her if the
examination is painful in any way.
5. Your ability to palpate the uterus and ovaries will depend
on the
patient's anatomy, the size of your hands,
and your level of skill.
Neurologic
Examination
Equipment
Needed
- Reflex
Hammer
- 128
and 512 (or 1024) Hz Tuning Forks
- A
Snellen Eye Chart or Pocket Vision Card
- Pen
Light or Otoscope
- Wooden
Handled Cotton Swabs
- Paper
Clips
General
Considerations
- Always
consider left to right symmetry
- Consider
central vs. peripheral deficits
- Organize
your thinking into seven categories:
1. Mental Status
2. Cranial Nerves
3. Motor
4. Coordination and Gait
5. Reflexes
6. Sensory
7. Special Tests
Mental
Status
The
Mini Mental Status Examination is a useful screening tool.
Cranial
Nerves
Observation
- Ptosis
(III)
- Facial
Droop or Asymmetry (VII)
- Hoarse
Voice (X)
- Articulation
of Words (V, VII, X, XII)
- Abnormal
Eye Position (III, IV, VI)
- Abnormal
or Asymmetrical Pupils (II, III)
I - Olfactory
Not Normally Tested
II - Optic
-
Examine the Optic Fundi
o Covered elsewhere..
- Test
Visual Acuity
1. Allow the patient to use his glasses or contact lens
if available.
You are interested in the patient's best-corrected
vision.
2. Position the patient 20 feet in front of the Snellen
eye chart (or hold a Rosenbaum
pocket card at a 14 inch "reading" distance).
3. Have the patient cover one eye at a time with a card.
4. Ask the patient to read progressively smaller letters
until he can
go no further.
5. Record the smallest line the patient read successfully
(20/20,
20/30, etc.) [2]
6. Repeat with the other eye.
- Screen
Visual Fields by Confrontation

0. Stand two feet in front of the patient and have him look
into your eyes.
1. Hold your hands about one foot away from the patient's
ears, and wiggle a finger on one hand.
2. Ask the patient to indicate on which side he sees the
finger move.
3. Repeat two or three times to test both temporal fields.
4. If an abnormality is suspected, test the four quadrants
of each eye while asking
the patient to cover the opposite eye with a
card.
- Test
Pupillary Reactions to Light
0. Dim the room lights as necessary.
1. Ask the patient to look into the distance.
2. Shine a bright light obliquely into each pupil in turn.
3. Look for both the direct (same eye) and consensual (other
eye)
reactions.
4. Record pupil size in mm and any asymmetry or irregularity.
5. If abnormal, proceed with the test for accommodation.
- Test
Pupillary Reactions to Accommodation
0. Hold your finger about 10cm from the patient's nose.
1. Ask him to alternate looking into the distance and at
your finger.
2. Observe the pupillary response in each eye.
III
- Oculomotor
- Observe
for Ptosis
- Test
Extraocular Movements
1. Stand or sit 3 to 6 feet in front of the patient.
2. Ask the patient to follow your finger with his eyes without
moving his head.
3. Check gaze in the six cardinal directions using a cross
or "H"
pattern.
4. Pause during upward and lateral gaze to check for nystagmus.
5. Check convergence by moving your finger toward the bridge
of the
patient's nose.
- Test
Pupillary Reactions to Light (See Above)
IV
- Trochlear
Test Extraocular Movements (Inward and
Down Movement, See
Above)
V
- Trigeminal
- Test
Temporal and Masseter Muscle Strength
1. Ask patient to both open his mouth and clench his teeth.
2. Palpate the temporal and masseter muscles as he does
this.
- Test
the Three Divisions for Pain Sensation
1. Explain what you intend to do.
2. Use a suitable sharp object to test the forehead, cheeks,
and jaw
on both sides.
3. Substitute a blunt object occasionally and ask the patient
to
report "sharp" or "dull."
- If
you find an abnormality then:
1. Test the three divisions for temperature sensation with
a tuning fork heated or
cooled by water.
2. Test the three divisions for sensation to light touch
using a wisp of
cotton.
- Test
the Corneal Reflex
1. Ask the patient to look up and away.
2. From the other side, touch the cornea lightly with a
fine wisp of
cotton.
3. Look for the normal blink reaction of both eyes.
4. Repeat on the other side.
5. Use of contact lens may decrease this response.
VI
- Abducens
Test Extraocular Movements (Lateral Movement,
See Above)
VII
- Facial
- Observe
for Any Facial Droop or Asymmetry
- Ask
Patient to do the following. Note any lag, weakness, or
asymmetry:
1. Raise eyebrows
2. Close both eyes to resistance
3. Smile
4. Frown
5. Show teeth
6. Puff out cheeks
- Test
the Corneal Reflex (See Above)
VIII
- Acoustic
- Screen
Hearing
1. Face the patient and hold out your arms with your fingers
near each ear.
2. Rub your fingers together on one side while moving the
fingers
noiselessly on the other.
3. Ask the patient to tell you when and on which side he
hears the
rubbing.
4. Increase intensity as needed and note any asymmetry.
5. If abnormal, proceed with the Weber and Rinne tests.
- Test
for Lateralization (Weber)
1. Use a 512 Hz or 1024 Hz tuning fork.
2. Start the fork vibrating by tapping it on your opposite
hand.
3. Place the base of the tuning fork firmly on top of the
patient's
head.
4. Ask the patient where the sound appears to be coming
from
(normally in the midline).
- Compare
Air and Bone Conduction (Rinne)
1. Use a 512 Hz or 1024 Hz tuning fork.
2. Start the fork vibrating by tapping it on your opposite
hand.
3. Place the base of the tuning fork against the mastoid
bone behind
the ear.
4. When the patient no longer hears the sound, hold the
end of the fork near the
patient's ear (air conduction is normally greater than
bone conduction).
- Vestibular
Function is Not Normally Tested
IX
- Glossopharyngeal
See Vagus Nerve
X
- Vagus
- Listen
to the patient's voice. Is it hoarse or nasal?
- Ask
Patient to Swallow
- Ask
Patient to Say "Ah"
o Watch the movements of the soft palate and the pharynx.
- Test
Gag Reflex (Unconscious/Uncooperative Patient)
1. Stimulate the back of the throat on each side.
2. It is normal to gag after each stimulus.
XI
- Accessory
- From
behind, look for atrophy or asymmetry of the trapezius muscles.
- Ask
patient to shrug shoulders against resistance.
- Ask
patient to turn his head against resistance. Watch and palpate
the sternomastoid muscle on the opposite side.
XII
- Hypoglossal
- Listen
to the articulation of the patient's words.
- Observe
the tongue as it lies in the mouth
- Ask
patient to:
1. Protrude tongue
2. Move tongue from side to side
Motor
Observation
- Involuntary
Movements
- Muscle
Symmetry
o Left to Right
o Proximal vs. Distal
- Atrophy
o Pay particular attention to the hands, shoulders, and
thighs.
- Gait
Muscle
Tone
1. Ask the patient to relax.
2. Flex and extend the patient's fingers, wrist, and elbow.
3. Flex and extend patient's ankle and knee.
4. There is normally a small, continuous resistance to passive
movement.
5. Observe for decreased (flaccid) or increased (rigid/spastic)
tone.
Muscle
Strength
- Test
strength by having the patient move against your resistance.
- Always
compare one side to the other.
- Grade
strength on a scale from 0 to 5 "out of five":
|
Grading
Motor Strength
|
|
Grade
|
Description
|
| 0/5 |
No muscle movement |
| 1/5 |
Visible muscle movement, but no movement at the joint |
| 2/5 |
Movement at the joint, but not against gravity |
| 3/5 |
Movement
against gravity, but not against added resistance |
| 4/5 |
Movement against resistance, but less than normal |
| 5/5 |
Normal strength |
- Test
the following:
1. Flexion at the elbow (C5, C6, biceps)
2. Extension at the elbow (C6, C7, C8, triceps)
3. Extension at the wrist (C6, C7, C8, radial nerve)
4. Squeeze two of your fingers as hard as possible ("grip,"
C7, C8,
T1)
5. Finger abduction (C8, T1, ulnar nerve)
6. Opposition of the thumb (C8, T1, median nerve)
7. Flexion at the hip (L2, L3, L4, iliopsoas)
8. Adduction at the hips (L2, L3, L4, adductors)
9. Abduction at the hips (L4, L5, S1, gluteus medius and
minimus)
10. Extension at the hips (S1, gluteus maximus)
11. Extension at the knee (L2, L3, L4, quadriceps)
12. Flexion at the knee (L4, L5, S1, S2, hamstrings)
13. Dorsiflexion at the ankle (L4, L5)
14. Plantar flexion (S1)
Pronator
Drift
1. Ask the patient to stand for 20-30 seconds with both arms
straight forward, palms up, and eyes
closed.
2. Instruct the patient to keep the arms still while you tap
them briskly
downward.
3. The patient will not be able to maintain extension and
supination (and
"drift into pronation) with upper
motor neuron disease.
Coordination
and Gait
Rapid
Alternating Movements
1.
Ask the patient to strike one hand on the thigh, raise the
hand, turn it over, and then strike it
back down as fast as possible.
2. Ask the patient to tap the distal thumb with the tip of
the index finger as fast as possible.
3. Ask the patient to tap your hand with the ball of each
foot as fast as possible.
Point-to-Point
Movements
1.
Ask the patient to touch your index finger and his nose alternately
several times. Move your finger about as
the patient performs this task.
2. Hold your finger still so that the patient can touch it
with one arm and finger outstretched. Ask
the patient to move his arm and return to
your finger with his eyes closed.
3. Ask the patient to place one heel on the opposite knee
and run it down
the shin to the big toe. Repeat with the
patient's eyes closed.
Romberg
1.
Be prepared to catch the patient if he is unstable.
2. Ask the patient to stand with the feet together and eyes
closed for 5-
10 seconds without support.
3. The test is said to be positive if the patient becomes
unstable (indicating a vestibular or proprioceptive problem).
Gait
Ask
the patient to:
1. Walk across the room, turn and come back
2. Walk heel-to-toe in a straight line
3. Walk on his toes in a straight line
4. Walk on his heels in a straight line
5. Hop in place on each foot
6. Do a shallow knee bend
7. Rise from a sitting position
Reflexes
Deep
Tendon Reflexes
- The
patient must be relaxed and positioned properly before starting.
- Reflex
response depends on the force of your stimulus. Use no more
force than you need to provoke a definite response.
- Reflexes
can be reinforced by having the patient perform isometric
contraction of other muscles (clenched teeth).
- Reflexes
should be graded on a 0 to 4 "plus" scale:
|
Tendon
Reflex Grading Scale
|
|
Grade
|
Description
|
| 0 |
Absent |
| 1+
or + |
Hypoactive |
| 2+
or ++ |
"Normal" |
| 3+
or +++ |
Hyperactive without clonus |
| 4+
or ++++ |
Hyperactive with clonus |
- Biceps
(C5, C6)
1. The patient's arm should be partially flexed at the elbow
with the palm down.
2. Place your thumb or finger firmly on the biceps tendon.
3. Strike your finger with the reflex hammer.
4. You should feel the response even if you can't see it.
- Triceps
(C6, C7)
1. Support the upper arm and let the patient's forearm hang
free.
2. Strike the triceps tendon above the elbow with the broad
side of
the hammer.
3. If the patient is sitting or lying down, flex the patient's
arm at the
elbow and hold it close to the chest.
- Brachioradialis
(C5, C6)
1. Have the patient rest the forearm on the abdomen or lap.
2. Strike the radius about 1-2 inches above the wrist.
3. Watch for flexion and supination of the forearm.
- Abdominal
(T8, T9, T10, T11, T12)
1. Use a blunt object such as a key or tongue blade.
2. Stroke the abdomen lightly on each side in an inward
and
downward direction above (T8, T9, T10)
and below the umbilicus
(T10, T11, T12).
3. Note the contraction of the abdominal muscles and deviation
of
the umbilicus towards the stimulus.
- Knee
(L2, L3, L4)
1. Have the patient sit or lie down with the knee flexed.
2. Strike the patellar tendon just below the patella.
3. Note contraction of the quadriceps and extension of the
knee.
- Ankle
(S1, S2)
1. Dorsiflex the foot at the ankle.
2. Strike the Achilles tendon.
3. Watch and feel for plantar flexion at the ankle.
Clonus
If
the reflexes seem hyperactive, test for ankle clonus:
1. Support the knee in a partly flexed position.
2. With the patient relaxed, quickly dorsiflex the foot.
3. Observe for rhythmic oscillations.
Plantar
Response (Babinski)
1.
Stroke the lateral aspect of the sole of each foot with the
end of a
reflex hammer or key.
2. Note movement of the toes, normally flexion (withdrawal).
3. Extension of the big toe with fanning of the other toes
is abnormal.
This is referred to as a positive Babinski.
Sensory
General
- Explain
each test before you do it.
- Unless
otherwise specified, the patient's eyes should be closed
during the actual testing.
- Compare
symmetrical areas on the two sides of the body.
- Also
compare distal and proximal areas of the extremities.
- When
you detect an area of sensory loss, map out its boundaries
in detail.
Vibration
- Use
a low-pitched tuning fork (128Hz).
1. Test with a non-vibrating tuning fork first to ensure
that the
patient is responding to the correct
stimulus.
2. Place the stem of the fork over the distal interphalangeal
joint of
the patient's index fingers and big toes.
3. Ask the patient to tell you if he feels the vibration.
- If
vibration sense is impaired proceed proximally:
1. Wrists
2. Elbows
3. Medial malleoli
4. Patellars
5. Anterior superior iliac spines
6. Spinous processes
7. Clavicles
Subjective
Light Touch
- Use
your fingers to touch the skin lightly on both sides simultaneously.
- Test
several areas on both the upper and lower extremities.
- Ask
the patient to tell you if there is difference from side
to side or other "strange" sensations.
Position
Sense
1.
Grasp the patient's big toe and hold it away from the other
toes to
avoid friction.
2. Show the patient "up" and "down."
3. With the patient's eyes closed ask the patient to identify
the direction
you move the toe.
4. If position sense is impaired move proximally to test the
ankle joint.
5. Test the fingers in a similar fashion.
6. If indicated move proximally to the metacarpophalangeal
joints, wrists,
and elbows.
Dermatomal
Testing
If
vibration, position sense, and subjective light touch are
normal in the fingers and toes you may assume the rest of
this exam will be normal.
Pain
- Use
a suitable sharp object to test "sharp" or "dull"
sensation.
- Test
the following areas:
1. Shoulders (C4)
2. Inner and outer aspects of the forearms (C6 and T1)
3. Thumbs and little fingers (C6 and C8)
4. Front of both thighs (L2)
5. Medial and lateral aspect of both calves (L4 and L5)
6. Little toes (S1)
Temperature
- Often
omitted if pain sensation is normal.
- Use
a tuning fork heated or cooled by water and ask the patient
to identify "hot" or "cold."
- Test
the following areas:
1. Shoulders (C4)
2. Inner and outer aspects of the forearms (C6 and T1)
3. Thumbs and little fingers (C6 and C8)
4. Front of both thighs (L2)
5. Medial and lateral aspect of both calves (L4 and L5)
6. Little toes (S1)
Light
Touch
- Use
a fine whisp of cotton or your fingers to touch the skin
lightly.
- Ask
the patient to respond whenever a touch is felt.
- Test
the following areas:
1. Shoulders (C4)
2. Inner and outer aspects of the forearms (C6 and T1)
3. Thumbs and little fingers (C6 and C8)
4. Front of both thighs (L2)
5. Medial and lateral aspect of both calves (L4 and L5)
6. Little toes (S1)
Discrimination
Since
these tests are dependent on touch and position sense, they
cannot be performed when the tests above are clearly abnormal.
- Graphesthesia
1. With the blunt end of a pen or pencil, draw a large number
in the
patient's palm.
2. Ask the patient to identify the number.
- Stereognosis
1. Use as an alternative to graphesthesia.
2. Place a familiar object in the patient's hand (coin,
paper clip,
pencil, etc.).
3. Ask the patient to tell you what it is.
- Two
Point Discrimination
1. Use in situations where more quantitative data is needed,
such as
following the progression of a cortical
lesion.
2. Use an opened paper clip to touch the patient's finger
pads in two
places simultaneously.
3. Alternate irregularly with one point touch.
4. Ask the patient to identify "one" or "two."
5. Find the minimal distance at which the patient can discriminate.
Notes
1.
For more information refer to A Guide to Physical Examination
and
History Taking, Seventh Edition by Barbara Bates, published
by
Lippincott in 1999.
2. Visual acuity is reported as a pair of numbers (20/20)
where the first
number is how far the patient is from the
chart and the second number
is the distance from which the "normal"
eye can read a line of letters.
For example, 20/40 means that at 20 feet
the patient can only read
letters a "normal" person can
read from twice that distance.
3. You may, instead of wiggling a finger, raise one or two
fingers
(unilaterally or bilaterally) and have
the patient state how many fingers
(total, both sides) they see. To test for
neglect, on some trials wiggle
your right and left fingers simultaneously.
The patient should see
movement in both hands.
4. PERRLA is a common abbreviation that stands for "Pupils
Equal Round
Reactive to Light and Accommodation."
The use of this term is so
routine that it is often used incorrectly.
If you did not specifically
check the accommodation reaction use the
term PERRL. Pupils with a
diminished response to light but a normal
response to accommodation
(Argyll-Robertson Pupils) are a sign of
neurosyphilis.
5. Nystagmus is a rhythmic oscillation of the eyes. Horizontal
nystagmus
is described as being either "leftward"
or "rightward" based on the
direction of the fast component.
6. Testing Pain Sensation - Use a new object for each patient.
Break a
wooden cotton swab to create a sharp end.
The cotton end can be
used for a dull stimulus. Do not go from
patient to patient with a
safety pin. Do not use non-disposable instruments
such as those found
in certain reflex hammers. Do not use very
sharp items such as
hypodermic needles.
7. Central vs Peripheral - With a unilateral central nervous
system lesion
(stroke), function is preserved over the
upper part of the face
(forehead, eyebrows, eyelids). With a peripheral
nerve lesion (Bell's
Palsy), the entire face is involved.
8. The hearing screening procedure presented by Bates on page
181 is
more complex than necessary. The technique
presented in this syllabus
is preferred.
9. Deviation of the tongue or jaw is toward the side of the
lesion.
10. Although it is often tested, grip strength is not a particularly
good
test in this context. Grip strength may
be omitted if finger abduction
and thumb opposition have been tested.
11. The "anti-gravity" muscles are difficult to
assess adequately with
manual testing. Useful alternatives include:
walk on toes
(plantarflexion); rise from a chair without
using the arms (hip extensors
and knee extensors); step up on a step,
once with each leg (hip
extensors and knee extensors).
12. Subjective light touch is a quick survey for "strange"
or asymmetrical
sensations only, not a formal test of dermatomes.
Mini
Mental Status Examination
The
"Mini" Mental Status Exam is a quick way to evaluate
cognitive function. It is often used to screen for dementia
or monitor its progression. [See Page 120 in Bates A Guide
to Physical Examination, 7th Ed ]

Chest X-ray Analysis
As a result of the patient interview and examination, the
caregivers can form some initial conclusions regarding a diagnosis
of the patients condition. These conclusions will prove
valuable in helping the caregivers assure that the therapeutic
modalities prescribed by the physician are best suited for
the patient.
In
addition to interviewing and examining patients, caregivers
need to be able to evaluate a patients chest x-rays.
This module is not intended to provide you with the interpretive
skills of a radiologic technologist. It is designed to enable
you to recognize structures and basic areas of normality and
abnormality Diagnostic radiographs of the chest are an important
part of the evaluation of the patient with respiratory complaints.
In
a chest radiograph, you can see the patients heart left-center,
and the left ventricle will appear to be most prominent. The
other features that can be observed include:
- Aortic
knob: It lies superior to the heart, and can
be distinguished by its rounded appearance.
- Right
atrium: Along with the superior vena cava, it
appears to be the hearts border on the right side.
- Descending
aorta: Appears posteriorly to the heart in lateral
view x-rays.
- Lungs:
Appear on both side of the chest, and have the look of translucent
shadows.
- Diaphragm:
This dome-shaped structure can be seen located along the
inferior border of the chests cavity. Its right side
is slightly (2 cm) higher because of the location of the
liver.
- Hilum:
Can be seen in the medial area of the chest, and its pulmonary
vessels and lymph nodes appear to be a branching density.
X-rays also reveal the presence of infiltrates, which are
usually caused by blood or body fluids accumulating in the
vascular space. These appear as darkened or clouded areas
on the radiographs. When the alveoli fill with fluids or
the tissues consolidate around the bronchus, that area will
be clearly visible on the radiograph. If a density or clouded
area appears to be anterior to the heart, the border will
be obscured. Densities lying posteriorly to the heart do
not obscure the hearts border.
The
most common and useful chest x-rays are the posterior-anterior
(PA) views; however, bedside radiographs sometimes are required
as a result of the patients condition. These portable
x-rays dont allow as much control of positioning or
film exposure, and in AP films, the heart usually appears
larger because it is a greater distance from the film plate.
Some
of the other radiographic procedures that can facilitate diagnosis
of a patient include:
- Fluoroscopy:
This
technique permits the heart and lungs can be viewed in motion.
It facilitates the diagnosis of paralysis of any part of
the diaphragm since it can be observed moving during the
patients breathing process.
- Inspiration/Expiration
Films: These radiographs are taken as the patient
breathes maximally in and out. They can help confirm the
presence of bronchial obstructions, including tumors or
blebs frequently seen in COPD patients.
- Oblique
views: Taken at approximately a 45° angle to
the film plate, these chest views allow a review of the
hearts more difficult to see areas, and facilitate
assessing its size. Effective viewing of the lung apices
is permitted by the lordotic view, which involves lifting
the clavicles away from the lung tissue.
- Computed
tomography (CT): This technique utilizes computer
technology to evaluate "slices" of lung density
data. It is valuable and effective for: observing focal
lung lesions beneath bony areas, identifying the bullae
and blebs seen in pulmonary emphysema, helping physicians
analyze the lesions seen in lung cancer prior to performing
surgery.
- Magnetic
resonance imaging (MRI): This non-invasive painless
technique involving electromagnetic field technology has
proven to be valuable in evaluating the possibility of cancer
in the chest wall and mediastinum; and has proven useful
for diagnosing thoracic aneurysms, congenital anomalies,
and major vessels of the aorta.
- Bronchoscopy:
This technique involves insertion of a fiberoptic
endoscope into the bronchi, and has become most valuable
for diagnosing the presence of lung cancer. The following
are 3D images via virtual bronchoscopy:
3D
Imaging of the Trachea
3D imaging of a normal trachea
3D virtual bronchoscopy of normal airway
Tracheal
stenosis with virtual imaging
Tracheal stenosis with 3D virtual bronchoscopy
- Computed
tomography (CT): This technique utilizes computer
technology to evaluate "slices" of lung density
data. It is valuable and effective for: observing focal
lung lesions beneath bony areas, identifying the bullae
and blebs seen in pulmonary emphysema, and helping physicians
analyze the lesions seen in lung cancer prior to performing
surgery.
- Magnetic
resonance imaging (MRI): This non-invasive painless
technique involving electromagnetic field technology has
proven to be valuable in evaluating the possibility of cancer
in the chest wall and mediastinum; and has proven useful
for diagnosing thoracic aneurysms, congenital anomalies,
and major vessels of the aorta.

Sputum Analysis
Mucus
Production and Sputum
Mucus
is produced in the goblet cells and the bronchial glands.
The goblet cells are located in the epithelial layer of the
tracheobronchial tree while the bronchial glands are located
below the epithelial layer. The fluid secreted by the bronchial
glands is much more watery than the goblet cell fluid.
Mucus
is expelled by coughing or clearing the throat. Once it is
expelled, mucus is called sputum. The major components of
sputum are 95% water, 2% mucus, 1% carbohydrates, and 1% lipids.
The two layers of sputum are called the sol layer and the
gel layer.
The
sol layer is in direct contact with the cilia of the lungs
which act to propel particles out of the tracheobronchial
tree. The gel layer, which is thicker, lies adjacent to the
inner bronchial surface. The process of moving secretions
out of the tracheobronchial tree is called mucociliary transport.
Some of the factors that slow down the transport process are
cigarette smoking, dehydration, and positive pressure ventilation.
The
group of drugs designed to break down mucus are called mucolytic
agents. These agents work primarily in four ways: some increase
the depth of the sol layer such as water and saline, some
decrease the viscosity of the gel layer such as acetylcysteine,
some decrease the adhesiveness of the gel layer such as propylene
glycol, and some increase ciliary activity such as the sympathomimetic
drugs.
Analysis:
Sputum Culture and Sensitivity
As
mentioned, sputum is the material brought up by coughing and
clearing of the respiratory tract. Sputum may contain mucus,
blood, pus, cellular debris, and microorganisms. Sputum that
is used for laboratory analysis must be obtained from the
bronchi, and not from the back of the throat, postnasal region,
or the oral cavity. Secretions expelled from the lungs and
tracheobronchial tree are specifically referred to as phlegm.
A
pure sputum specimen is one that is not contaminated by saliva
from the oropharynx or by secretions from the nasal sinuses.
A sputum sample must be obtained by either having the patient
expectorate it or by suctioning the patient. The best time
to obtain a specimen is in the early morning since secretions
tend to collect in the patient's chest during sleep. To obtain
a fresh, uncontaminated specimen the patient should be instructed
to rinse out the mouth with water. The patient can then take
several deep breaths and cough from the diaphragm. Approximately
1 to 3 ml of sputum should be collected in a sterile container.
If
the laboratory detects a large number of epithelial cells
that indicate saliva in the specimen, it will be discarded
and another one will have to be obtained. Some maintain that
a specimen containing >25 squamous epithelial cells/lpf
is indicative of oropharyngeal contamination. A preponderance
of neutrophils, ciliated epithelial cells, or alveolar macrophages
with <10 squamous epithelial cells/lpf is indicative of
lower respiratory secretions.
If
the patient cannot produce a specimen because of minimal secretions
or an inadequate cough, they will either need to be suctioned
or have the sputum induced. A sputum induction can be done
by giving an aerosol nebulizer treatment containing either
normal or hypertonic sodium chloride and/or performing postural
drainage or chest percussion. If this fails the patient will
have to be nasotracheally suctioned if the physician so orders.
After
the specimen is properly obtained and placed in a sterile
container, it is sent to the laboratory for analysis. The
specimen should reach the laboratory within 1 hour of collection.
Once it reaches the lab, the technician will place it on nutrient-containing
media that will enhance the growth of the microorganism. A
sample of sputum is then applied as a very thin layer to a
microscope slide and then stained with a violet stain known
as a gram stain. Bacteria that retain a violet color after
they're stained with crystal violet and washed with ethanol
are gram-positive. If the bacteria lose the violet color,
they are referred to as gram-negative.
The
color, number, and morphologic appearance of the cells make
it possible to identify the genus of the organism. Gram staining
helps the physician select an initial antibiotic until the
lab completes a full culture and sensitivity testing of the
organisms. The results of the gram stain may lead to a presumptive
diagnosis of bacterial pneumonia if large numbers are found.
After
the specimen is identified, the laboratory will test its sensitivity
to antimicrobial drugs so that the physician can select a
specific drug to combat the infection. The laboratory will
use either an automated system or disc diffusion to determine
an organism's susceptibility to a drug. The automated system
will give a minimum inhibitory concentration (MIC). The MIC
is an exact quantitative value where the smaller the number,
the more effective the drug will be.
In
the disc diffusion method, the organism is grown on agar in
a Petri dish and various drugs are placed on the agar to determine
responses. If the drug is effective, a clear area will appear
around the disc of the drug. This area where the drug has
eradicated the organism is called the zone of inhibition.
The larger the zone, the more sensitive the microorganism
is to the antibiotic. A final report will include the organisms
cultured and what drugs they're sensitive to.
On
the report, normal flora should be differentiated from pathogens.
Different areas of the body have differing amounts and types
of flora. Also, the number of colonies (a group of bacteria
in a culture that derived from a single organism) that were
grown should be reviewed. When reporting sputum specimens,
the laboratory will report these as "normal flora"
or they will identify the specific pathogens involved. Other
descriptive terms used include scant, moderate, or numerous
to differentiate the quantity..

Microbiologic
Tests
Gram
Stain
Bacterial
organisms are broadly classified into one of four groups by
performing a gram stain. The classifications include:
1. Gram-positive rods
2. Gram-positive cocci
3. Gram-negative rods
4. Gram-negative cocci
The
bacteria can be then be further classified as being either
aerobic or anaerobic.
Cultures
and Sensitivity Tests
Cultures
involve the propagation of microorganisms or living tissue
cells in special media conducive to their growth. These tests
are performed whenever identification of specific organisms
is needed to prescribe therapies. Most cultures can be completed
within two or three days, but some, such as mycobacterium
tuberculosis, can take as long as eight weeks. Once the organism
has been identified, it is necessary to conduct sensitivity
tests to ascertain the most appropriate and effective antibiotic
therapy.
Using
a technique called the acid-fast stain generally tests for
the presence of mycobacterium organisms. Urinalysis is used
to diagnose diseases involving the liver, kidney, cardiovascular,
and endocrine systems. Pleural fluid analysis is used to distinguish
transudate and exudate fluids in the pleural space.

Carbon Dioxide
Challenge Test
The
Carbon Dioxide Challenge Test is used to measure the increase
or decrease in minute ventilation caused by breathing various
concentrations of carbon dioxide under normal oxygen conditions.
The test is particularly useful in determining the effects
of carbon dioxide on the respiratory system of patients suspected
of decreased ventilatory drive to carbon dioxide. Other names
for the carbon dioxide challenge test include the C02 response
test and the hypercapnic challenge test.
The
Carbon Dioxide Challenge Test can be measured by either the
open-circuit technique or the closed-circuit technique. In
the open-circuit technique the patient breathes various concentrations
(1% to 7%) carbon dioxide from a demand valve or reservoir
until a steady state is reached.
With
the closed-circuit technique or rebreathing technique, the
patient rebreathes from a one-way circuit. A 6 to 10 Liter
anesthesia bag is filled with a volume equal to the patient's
vital capacity plus 1 Liter of a gas mixture containing 7%
C02 and 93% 02. The 7% C02 is chosen to approximate average
mixed venous concentrations of C02, and the 93% 02 is chosen
to eliminate concern for hypoxia during the test.
After
normal breathing followed by a full expiration, valves are
turned that provide the anesthesia bag as a reservoir for
ventilation during the test. Exhaled gases are returned to
the bag. End-tidal C02 is monitored during the test. If occlusion
pressures are desired (pressure generated at the mouth with
an occluded airway), the inspiratory portion of the circuit
is occluded by means of a Starling resistor at random intervals
throughout the test. The output of a pressure transducer is
then recorded on a high speed recorder. Changes in minute
ventilation are monitored and plotted against the End-tidal
C02 to obtain a response curve. The test continues until:
- 4
minutes have elapsed or
- the
patient's end-tidal CO2 concentration equals 9% or
- when
the patient complains of dyspnea
- the
first 30 seconds of rebreathing are excluded from data analysis.
Preparations
for the test will include the avoidance of respiratory stimulants
such as caffeine containing beverages (coffee, tea, cola),
theophylline preparations, medroxyprogesterone, and protriptyline
should be discontinued for at least 12 hours before testing
unless the effects of these substances on ventilatory response
to C02 is desired. Complications may include a generalized
vasodilatation that may cause flushing, diaphoresis, and headaches.
The
normal response to increased levels of PaC02 is a linear increase
in minute ventilation of approximately 3 L/min/mm Hg. The
normal range of response may vary from 1 to 6 L/min/mm Hg
PC02. In some patients with COPD the response to elevated
C02 may be reduced. These patients with C02 retention receive
their primary stimulus to breath from the hypoxemic response.
Other patients with myxedema, obesity-hypoventilation syndrome,
obstructive sleep apnea, and idiopathic hypoventilation may
also show a marked decreased response to hypoxemia or hypercapnia.
Occlusion
pressure is the pressure generated at the mouth during the
first 100 msec of an inspiratory effort against an occluded
airway. The occlusion pressure measured at 100 msec is a relatively
direct indicator of the output of the respiratory center to
the diaphragm and is independent of airflow obstruction. Normal
values for a normocapnic P100 is 2.6 cm H20 (range 1.5-5).
The occlusion pressure may increase at a rate of approximately
0.5-6 cm H20 for every mm increase in end-tidal C02. Some
patients with COPD may show no increase in their P100 in response
to elevated PC02 levels.
Hypercapnic
patients who exhibit PC02 values greater than 55 mm Hg at
rest will not usually provide a sufficient sample to plot
the ventilatory response by the end of the test (63 mm Hg).
Voluntary erratic breathing will yield misleading data. Interpretation
may be difficult since a wide range of normal responses exist.

Testing Patients'
Pulmonary Function (PFTs)
Pulmonary
Function Testing (PFT's) refers to a series of diagnostic
studies done in an outpatient setting that can yield valuable
information to your physician. When properly performed and
interpreted they can help diagnose the cause of a symptom
(such as shortness of breath), the extent of a disease (such
as Emphysema), and help determine the efficacy of therapy
(such as how effective are corticosteroids in treating a patient
with Idiopathic Pulmonary Fibrosis).
A
patients pulmonary function status can deteriorate without
exhibiting any changes in symptoms. For example, asthmatic
patients recovering from an acute attack can be asymptomatic
for some time prior to flow rates returning to normal. The
spirometry of PFT can determine the patients vital capacity,
with expiratory flow rates being useful in identifying airway
obstructions.
The
Spirogram
There
are three parts to a complete PFT. Most basic is the Spirogram.
In this test a patient blows into the testing apparatus as
rapidly and as hard as they can for as long as they are able.
Two good trials are required for an accurate test. This test
measures the air flow and is useful in detecting the presence
and severity of such obstructive airways diseases as Asthma.
If the Spirogram is abnormal, a bronchodilator medication
is usually given to the patient, and the Spirogram is then
repeated. Any improvement after the inhalation of the Bronchodilator
agent suggests the patient may benefit in the chronic use
of similar agents.
Lung
Volume Determinations
Lung
Volume determinations are the second component of a complete
PFT. This is not a forced maneuver. The patient breathes a
special gas mixture with a normal respiratory effort for about
three minutes and then slowly exhales. By using mathematical
calculations, it is possible to determine not only the volume
of gas in the lung, but also to subdivide the total volume
of gas in the lung into clinically useful compartments. If
there is less then the normal amount of gas in the lung, a
restrictive disease such as Idiopathic Pulmonary Fibrosis
may be suggested.
The
Diffusion Capacity
The
Diffusion Capacity is the final component of a complete PFT.
In this test the patient exhales fully, the breathes in another
special mixture of gas. A component of this gas mixture rapidly
diffuses from the airway into the blood. When the patient
exhales after about 10 seconds of breath holding , the expired
breath is collected in an air tight bag and analyzed. The
results of the diffusion capacity test correlates with the
body's ability to extract oxygen from the lungs. It is the
most difficult of the Pulmonary Function Tests to accurately
interpret, but a low diffusion capacity is usually a sign
of advanced disease in patients with Emphysema or Idiopathic
Pulmonary Fibrosis.
Ventilatory
Status and Parameters
It
is important that the attending caregivers be aware of their
patients ability to breathe spontaneously and without
any ventilatory assistance. Patients need to be able to increase
the depth and rate of their breathing without becoming fatigued.
Patients without an adequate ventilatory reserve to deal with
normal daily stressors are at risk for developing life-threatening
respiratory distress.
Caregivers
can evaluate this reserve by evaluating the data obtained
from performing various bedside assessment procedures, including:
- Tidal
Volume (VT): By having a patient breathe normally
through a respirometer, the caregivers can obtain the patients
tidal volume. The VT is obtained by averaging the expired
volume over the period of a minute. It can be determined
as a calculation of minute ventilation, and normally should
be at least 5-7 ml/kg of the patients body weight
to be sufficient to maintain adequate ventilation without
assistance.
- Minute
Ventilation (VE): This can be measured by counting
the patients respiratory while he exhales when breathing
normally through a spirometer for one minute. The total
amount of exhaled gas in a minute equals the patients
minute ventilation. Total average tidal volume is then calculated
by dividing VE by the respiratory rate. 5-10 l/min is considered
a normal.
- Forced
Vital Capacity (FVC): To ascertain ventilatory
reserve under stress (forced vital capacity) have the patient
inspire maximally and then exhale as fast and completely
as possible through the spirometer. If the FVC is less than
10-15 ml/kg body weight, the patient may need ventilatory
assistance.
- Maximal
Inspiratory Force (MIF): Patients need to have
an acceptable level of respiratory muscle strength in order
to maintain an adequate vital capacity. MIF can be measured
by using a pressure manometer. Patients need to be strong
enough to exert a MIF of at least -20 cm H2O to be considered
normal and adequate.
- Peak
Expiratory Flow Rate (PEFR): The existence and
degree of airway obstruction and the patients response
to aerosolized bronchodilators can be measured at bedside
by evaluating the patients maximum rate of air flow
expelled during a forced expiration.
Conclusion
Pulmonary
Function Testing (PFT's)is thus useful in diagnosis of the
cause of symptoms (such as shortness of breath). PFT's can
determine the potential efficacy of therapy (will a Bronchodilator
work), suggest the severity of a lung disease and be used
to follow the course of a lung illness and its response to
therapy.

Arterial Blood
Gas Analysis (ABG's)
Introduction
Arterial
Blood Gas Analysis(ABG's) along with Pulmonary Function Testing(PFT's)
form the two cornerstones of the physiologic testing of lung
function. PFT's have been discussed elsewhere and share with
ABG's the ability to help with the diagnosis and treatment
of a vast variety of diseases and disorders.
Sample
technique
To
obtain a blood sample for ABG's, a needle is placed in an
artery. The Radial Artery is the usual source of the blood
sample used for ABG's. This artery runs in the wrist and is
close enough to the skin surface to be easily entered with
a small needle. The arterial puncture is usually preceded
with an Allen's Test that assures an adequate collateral blood
flow through the wrist. The sample is collected under sterile
conditions and run through an analyzer.
Sample
Analysis and Results
The
analyzer produces three main measurements: arterial pH, paO2
and paCO2.
The
arterial pH is a measure of the body's acid-base equilibrium.
The body possesses many powerful mechanisms that attempt to
maintain the pH within a very narrow range. Any major alteration
of the pH can prove fatal and treatments must be begun to
normalize the pH as rapidly as possible.
The arterial paO2 measures the oxygenation of the blood. A
low paO2 can also prove fatal and appropriate oxygen therapy
is usually given to correct a low paO2.
The
arterial paCO2 measures the bodys ability to excrete
the metabolic byproduct CO2(carbon dioxide). The ability to
excrete CO2 is one of the major respiratory functions of the
lung. An elevated paCO2 may suggest a problem with lung ventilation
that could progress to require mechanical ventilation. A low
paCO2 may suggest a metabolic problem.
Thus,
ABG's provide a valuable window on a range of potentially
life-threatening problems and are essential in following the
complex course of critically ill patients
Pulse
Oximetry Home Evaluation Test
Oxygen
therapy is the administration of oxygen at concentrations
greater than room air, with the intention of treating or preventing
the symptoms and manifestations of hypoxia in the home or
extended-care facility.
The
Pulse Oximetry Home Evaluation test or Desaturation Oximetry
test is used to determine the patient's level of arterial
oxygenation at rest and during exercise, movement, or sleep.
The oximetry report generally includes heart rate, resting
02 saturation, and the lowest functional 02 saturation during
whatever event is being monitored. A correlation of oxyhemoglobin
measured by blood oximetry ABGs and pulse oximetry should
be made to accurately verify the results. The external ECG
should correlate within 5 beats/minute of the pulse oximeter's
pulse display.
Guidelines
for reimbursement of home oxygen therapy state that a resting
arterial p02 < or = to 55 torr or a resting oxygen saturation
(Sp02%) < or = to 88% in association with specific clinical
conditions (cor pulmonale, congestive heart failure, or erythrocythemia
with hematocrit > 56) with evidence of improvement with
oxygen therapy qualify a patient for continuous oxygen therapy
reimbursement. Guidelines for reimbursement for nocturnal
and exercise oxygen therapy state that 02 saturations during
exercise or sleep that fall to < or = 88% that improve
with oxygen therapy will be reimbursed.
Because
of the limitations of pulse oximetry, decisions regarding
oxygen therapy should not be made on the basis of pulse oximetry
alone. Assessment of the Pa02 by arterial blood gases should
be done also.
Some
patients with Pa02 55 torr may be denied oxygen therapy if
the decision was based on pulse oximetry measurements alone.
Arterial
blood gas analysis is indicated whenever there is a major
change in the patient's cardiopulmonary status. These measurements
should be repeated in 1-3 months after in-hospital oxygen
therapy is begun, to determine long-term use. Once long-term
use has been documented, repeated arterial blood gas analysis
or oxygen saturation measurements are unnecessary unless there
is a need to follow the course of the disease, to assess changes
in the patient's clinical status, or to facilitate changes
in the amount of oxygen.
Equipment
commonly used for in-home oxygen use will include low-flow
oxygen delivery devices such as nasal cannulas, transtracheal
oxygen catheters, oxygen reservoir cannulae (nasal or pendant),
and demand oxygen delivery devices. Oxygen supply systems
will include oxygen concentrators, liquid oxygen systems,
and compressed gas cylinders.
Under
normal circumstances low-flow oxygen systems without humidifiers
do not pose an increased risk for infection and do not need
to be replaced on a routine basis.
Precautions
or possible complications from the use of home oxygen may
include:
1.
Oxygen administration may lead to an increase in PaCO2 in
those
patients who are C02 retainers.
2. Inadequate instruction in home oxygen therapy may result
in problems.
3. Complications may result from use of nasal cannulae or
transtracheal
catheters.
4. Increased oxygen concentrations may increase possible fire
hazards.
5. Bacterial contamination may result from certain nebulizers
and
humidification systems if not properly
maintained.
6. Physical hazards can result from unsecured cylinders, ungrounded
equipment, or mishandling of liquid oxygen
(resulting in burns).
Clinical
assessment of the patient receiving in-home oxygen therapy
should be routinely performed. Patients should be visited/monitored
at least once a month by credentialed personnel unless conditions
require more frequent visits. All oxygen delivery equipment
should be checked daily for proper functioning, prescribed
flow rates, oxygen percentage, liquid or compressed gas content,
and backup supply. The nurse or RCP should visit on a monthly
basis and go over needed information for the patient and family
to operate the equipment correctly.

Ventilation /
Perfusion Lung Scanning
Ventilation/perfusion
lung scanning involves the generation of an image by radiation
emitted from radioisotopes introduced into the lungs. The
V/Q scan involves two tests that are almost always combined;
the Ventilation scintiscan and the Perfusion scintiscan. When
combined together, they are commonly known as a V/Q scan.
The
primary indication for lung ventilation and perfusion imaging
is the detection of acute pulmonary emboli. In the Ventilation
scintiscan, lung fields are viewed following the inhalation
of a radioactive gas in order to determine the distribution
of ventilation. In the Perfusion scintiscan, radioactive particles
are injected into the blood stream intravenously and scanned
as the particles pass through the pulmonary bloodstream.
The
Ventilation Scintiscan is sometimes known as the radionuclide
ventilation lung scan, aerosol lung scan, ventilation lung
scan, and the xenon lung scan. In this procedure the patient
takes one or several breaths of a radioactive gas usually
containing xenon. Multiple images of the lungs are then taken
to assess lung ventilation. Radio-aerosols labeled with technetium
can also be used instead of xenon gas.
The
ventilation scintiscan measures the distribution pattern and
the volume of ventilation within the lungs. In addition to
testing for pulmonary emboli along with the perfusion scan,
lung ventilation imaging is also helpful in quantifying regional
pulmonary ventilation. This can be helpful when used in patients
with severe obstructive lung disease or who are being considered
for lung resection surgery. Normal findings in the test will
show a homogeneous distribution of activity throughout the
lungs.
The
Perfusion Scintiscan is sometimes known as the perfusion lung
scan, perfusion-ventilation scan, pulmonary scan, and radionuclide
perfusion lung scan. In this procedure the patient receives
an intravenous injection of albumin particles that are tagged
or labeled with a radioactive marker, such as iodine or technetium-99m
(99mTc). The albumin particles are trapped by the small arterioles
of the pulmonary circulation providing a pattern of gamma
radiation that indicates pulmonary perfusion. Multiple images
of the lungs are then acquired to assess lung perfusion.
Before
administering the perfusion scintiscan, the patient will have
blood work drawn prior to the injection of the radioactive
material. The patient will also have a routine chest radiograph
performed within 12 hours prior to imaging or receive one
immediately after. Caution should be taken before administering
the test for patients with known primary or secondary pulmonary
hypertension. The radioactive albumin can worsen the underlying
condition temporarily. The perfusion scan is nearly always
combined with a lung ventilation scan to detect patterns of
segmental perfusion deficits that occur alongside normal regional
ventilation. This is characteristic of pulmonary emboli.
A
number of diseases create abnormalities in either ventilation
or perfusion or both. The evaluation of a suspected pulmonary
embolism should begin with a ventilation-perfusion (V/Q) lung
scan. When an embolus is lodged within a pulmonary vessel,
a marked decrease or absence of pulmonary perfusion occurs
in the involved area. In the first 24 to 48 hours however,
ventilation to the area is maintained. This combination of
decreased perfusion along with normal ventilation is called
a non-matching ventilation/perfusion defect. If the area of
decreased perfusion becomes infarcted, then it is called a
matching ventilation/perfusion defect.
The
V/Q scan should be interpreted in conjunction with a current
chest radiograph along with clinical assessment. The V/Q scintigraphic
patterns can usually be classified in four categories: high
probability, intermediate probability (indeterminate), low
probability, and normal.
1.
A high probability interpretation is usually indicative of
pulmonary
embolism. The positive predictive value
of a high probability lung scan
result is around 90%. In the majority of
patients a high probability lung
scan confirms the diagnosis of pulmonary
embolism. A pulmonary
angiographic confirmation will usually
not be necessary unless the scan
result does not correlate with the clinical
picture.
2.
A normal/near normal pattern indicates that a pulmonary embolism
is
very unlikely. If the V/Q scan is normal/near
normal, no further workup
or treatment for pulmonary embolism is
needed.
3.
An intermediate probability (indeterminate) result may or
may not be an
indication of a pulmonary embolism. For
this group of patients a
pulmonary angiogram is needed for further
evaluation.
A
low probability lung scan makes the possibility of pulmonary
embolism remote when verification by clinical assessment is
lacking. If clinical signs are evident however, an angiogram
should be performed.

Interpreting
Laboratory Test Data
Blood
Panels
Blood
panels are group of tests used to determine the patients
condition. These groups of tests may be general in scope or
targeted to check for a specific disease or organ function.
The analysis most often can be performed using a small sample
of blood. The American Medical Association Current Procedural
Terminology (CPT) Board approved four new laboratory panels
in 1996. These include the electrolyte panel, the hepatic
function panel, the basic metabolic panel, and the comprehensive
metabolic panel.
Initially,
the major blood panel test was the Chemistry Panel. This test
is usually called Chem- followed by a number (Chem-7, Chem-16,
Chem-25) depending on how many tests are ordered. The Chemistry
Panel is a very common test to find out if a person may have
diabetes, kidney problems, problem with electrolytes, liver
problems, and/or elevation of cholesterol or triglycerides.
It may also include blood proteins, calcium, phosphorus, serum
iron, and muscle enzymes. The number of tests included in
the panel for each laboratory is different. The Chemistry
Panel is now being superseded by the Basic and the Comprehensive
Metabolic panel and is not being used to describe this grouping
of tests.
1.
Hepatic Function Panel. This panel focuses on liver
function and is used to diagnose and monitor conditions such
as hepatitis. Gallstones may also be detected using this panel.
These tests may also be used to check for liver disease while
the patient is being treated with certain drugs. The Hepatic
Function Panel includes:
1.
Hepatic Function Panel A
2.
Albumin; serum
3.
Bilirubin; total and direct
4.
Phosphatase; alkaline
5.
Transferase; aspartate amino (AST) (SGOT)
6.
Transferase; alanine amino (ALT) (SGPT)
2.
Electrolyte Panel - The electrolyte panel contains
tests which indicate of the amount of water and salt in the
body. These tests include sodium, potassium, chloride and
carbon dioxide. Some of the disorders that lead to imbalances
of the electrolytes include dehydration from vomiting or diarrhea,
and kidney disease. Certain drugs such as diuretics may also
affect the concentration of electrolytes in the body. The
Electrolytes Panel includes:
1. Carbon dioxide (bicarbonate)
2. Chloride; blood
3. Potassium; serum
4. Sodium; serum
3.
Basic Metabolic Panel - This group of tests is an extension
of the electrolyte panel and includes tests to measure kidney
function and glucose metabolism. The additional tests include
creatinine, glucose and BUN. The Basic Metabolic Panel consists
of:
1. Carbon dioxide (bicarbonate)
2. Chloride; blood
3. Creatinine; blood
4. Glucose; quantitative
5. Potassium; serum
6. Sodium; serum
7. Urea nitrogen; quantitative
4.
Comprehensive Metabolic Panel - This group of tests
combines almost all of the tests included in the Basic Metabolic
and Hepatic Panels. Bone health is also checked by evaluating
calcium, phosphate and alkaline phosphatase. The Comprehensive
Metabolic Panel includes:
1.
Albumin; serum
2.
Bilirubin; total
3.
Calcium; total
4.
Chloride; blood
5.
Creatinine; blood
6.
Glucose; quantitative
7.
Phosphatase; alkaline
8.
Potassium; serum
9.
Protein; total, except refractometry
10.
Sodium; serum
11.
Transferase; aspartate amino (AST) (SGOT)
12.
Urea nitrogen; quantitative
Components
of the Blood Chemistry Panel
-
Glucose is a measure of the sugar content in the
blood that is monitored to evaluate for diabetes or hypoglycemia.
This test needs to be performed in a fasted state. Normal
blood sugar should be between 70-110 mg/dl.
- Urea
Nitrogen (BUN) is a waste product of protein metabolism.
It is produced in the liver and excreted by the kidneys.
Normal values should be between 5-25 mg/dl. High values
may occur when protein metabolism is not functioning properly.
- Creatinine
is a waste product of protein metabolism also. It represents
the function of the kidneys. Normal serum concentration
should be between 0.7-1.3 mg/dl.
- Iron
is the most sensitive indicator of iron stores (in the absence
of liver disease or inflammation). Low values may represent
certain types of anemia and should be evaluated by a physician.
- Calcium
is involved in many physiologic processes. A normal blood
calcium level is essential for normal function of the heart,
nerves, and muscles. It is also involved in the coagulation
process.
- Phosphorus
is an essential element in the diet. It is a major component
of the mineral phase of bone and occurs in all tissues,
being involved in almost all metabolic processes. Calcium
is controlled by the kidneys and parathyroid glands. Processing
errors may affect this value.
- Uric
Acid is a constituent in the blood which transports
nitrogen in the body. It is normally excreted in the urine
to rid the body of nitrogen. Values that are high may indicate
gout, arthritis or certain kidney problems. A low value
is not clinically significant.
- Sodium
is an ion that is important in the conduction of nerves,
contraction of muscles, and functioning of cells. It is
controlled primarily by the kidneys and adrenal glands.
Normal levels range between 137 to 147 mEq/L.
- Potassium
is important for muscles and nerves function. Potassium
is controlled by the kidneys and is affected by diuretics
or cardiovascular medications. Normal levels range between
3.5 to 4.8 mEq/L.
- Chloride
is an ion that is important in the functioning of cells
as are sodium and potassium. It is primarily controlled
by the kidneys and adrenal glands. Normal levels range between
98 to 105 mEq/L.
- Total
Protein is the total amount of protein circulating in
the blood. This value represents general nutritional habits.
Normal levels range between 6.3 to 7.9 g/dl.
- Albumin
is a carbohydrate-free plasma protein which transports fatty
acids, bilirubin, and poorly saturated hormones. It also
serves as a reserve store of protein. Normal levels range
between 3.5 to 5.0 g/dl.
- Globulin
is a protein fraction. Elevated values may indicate chronic
infections.
- A/G
Ratio is a ratio between Albumin and Globulin. Provided
Albumin and Globulin values are normal, a high or low ratio
is not significant.
- Total
Bilirubin is a bile pigment. It normally circulates
in the plasma and is taken up by liver cells. High levels
of bilirubin may result in jaundice.
- LDH
stands for lactate dehydrogenase. It is an enzyme involved
in the breakdown of lactic acid. Anything which causes cellular
damage, including heart attacks, liver disease, and blood
drawing itself, may cause higher values.
- Alkaline
Phosphatase is an enzyme found primarily in bones and
the liver. Values for pregnant women may be elevated.
- SGOT
stands for serum glutamic oxaloacetic transaminase. SGOT
is a liver enzyme involved in cellular functions of the
heart muscle and liver. Alcohol consumption, liver disease,
and other normal factors may increase the value.
- SGPT
stands for serum glutamic pyruvic transaminase. SGPT, like
SGOT, is an enzyme involved in the functions of heart, liver,
and muscle cells. Alcohol consumption has been shown to
increase this value.
- GGT
stands for Gamma Glutamyl Transpeptidase. Similar to SGOT
and SGPT, GGT is an enzyme involved in the function of the
liver, heart, and muscle cells. Alcohol consumption, liver
disease, heart attacks, recent heavy physical exertion,
and other normal factors have been shown to raise this value.
- Cholesterol
is used to make essential body substances, such as cell
walls and hormones. High levels of cholesterol have been
associated with an increased risk for heart disease. Low
levels of cholesterol are preferred. Normal levels range
between 150 to 220 mg/dl.
- Triglycerides
are blood fats that are the usual storage form of lipids
in the body. This value can be affected by a recent meal
or recent physical activity. An eight hour fast with no
significant activity is required for accurate results.
- HDL
Cholesterol is a High Density Lipoprotein, and is commonly
referred to as the "good cholesterol. HDL Cholesterol
is a transport protein that carries cholesterol away from
the artery walls for removal from the body. The higher the
HDL value, the lower the risk of cardiovascular disease.
Exercise and weight loss have been shown to increase the
HDL level, while smoking has been shown to decrease it.
- LDL
Cholesterol is a Low Density Lipoprotein, and is commonly
referred to as the "bad" cholesterol. LDL Cholesterol,
like HDL Cholesterol, is a transport protein. However, LDL
transports cholesterol to the arteries. The lower the LDL
Cholesterol concentration, the lower the risk of cardiovascular
disease. A low-fat, low-cholesterol diet has been shown
to decrease this value.
- Cholesterol/HDL
Ratio is a ratio of Total Cholesterol to HDL Cholesterol.
This ratio has been shown to be a good predictor of cardiovascular
disease risk, with the lower the ratio the better. A combination
of regular aerobic exercise and good nutritional practices
have been shown to improve this ratio.
(Please
note that many books have differing numbers for normal values.
The above values have been taken from Robert Wilkins book
"Clinical Assessment in Respiratory Care")
Complete
Blood Count
The
Complete Blood Count (CBC) is one of the most routinely performed
laboratory tests used for obtaining information about the
patient's blood. The test is usually called a CBC with differential
(used to determine the different types of white blood cells).
The CBC with differential is a very common test that is done
to find out if a person is anemic, has an infection, or may
have a tendency to bleed.
The
CBC examines three major types of cells; red blood cells (RBCs),
white blood cells (WBCs), and platelets. The CBC involves
counting the number of red cells and white cells in the blood,
evaluating the red cell factors according to the size and
hemoglobin content of the cells, and examining the cells visually.
The CBC test consist of:
1.
Red blood cell count (RBC)
2. Hemoglobin (Hb)
3. Hematocrit (Hct)
4. Erythrocyte index - Mean cell volume (MCV), Mean cell hemoglobin
(MCH), and the Mean cell hemoglobin concentration
(MCHC)
5. White blood cell count (WBC) and the differential of the
white blood
cells - Platelet count
Red
blood cells (RBCs) are produced in the bone marrow by the
maturation of nucleated cells known as normoblasts. The basic
function of the RBC is to serve as a transport for hemoglobin,
the protein that carries oxygen to the tissues. The RBC circulates
for 120 days in the blood stream before being destroyed in
the body's reticuloendothelial system.
Examination of the red blood cell is done by:
-
Red Cell Count (or Erythrocyte count) refers to the
number of red blood cells. A machine known as a Coulter
Counter usually does this electronically. The result of
the test is expressed as number of cells per unit volume,
specifically cells/µL. A typical laboratory normal
range is 4.2 - 5.4 x 106/mm3 for females; for adult males
it is 4.6 - 6.2 x 106 /mm3.
- Hemoglobin
(Hgb) is a protein in the RBC that is responsible for
carrying oxygen to the tissues. It is formed in the bone
marrow. The normal range for hemoglobin is highly age and
sex-dependent, with men having higher values than women,
and adults having higher values than children (except for
neonates which have the highest values of all). Hemoglobin
results are traditionally expressed as unit mass per volume,
specifically grams per deciliter (g/dL). Typical lab values
for a young adult female will range between 12 - 15 g/dL;
for adult males it is 13.5 - 16.5 g/dL.
- Hematocrit
(Hct) - (also called the packed cell volume or PCV)
is the volume or percentage of red blood cells in whole
blood. The hematocrit is a measure of the total volume of
the erythrocytes relative to the total volume of whole blood
in a sample. The result is usually expressed as a percentage.
The normal range is 38-47% for females, and 40-54% for males.
- MCV
stands for mean corpuscular volume. This is the mean volume
of all the erythrocytes counted in the sample. The value
is traditionally expressed in cuµ. The normal range
is 80 - 96 cuµ in the adult. The formula for the calculation
in general terms is MCV = hematocrit ÷ RBC count.
- MCH
stands for mean cell hemoglobin. This is a measure of the
amount of hemoglobin associated with each red cell. The
MCH represents the mean mass of hemoglobin in the RBC and
is expressed in the mass unit, picograms. The value is determined
by the formula, MCH (in pg) = (hemoglobin [in g/dL] x 10
÷ (rbc count [in millions/µL]). Normal values
will run between 27-31 pg. The MCH tends to be similar to
that of the MCV and adds very little information.
- MCHC
stands for mean cell hemoglobin concentration. This value
represents the mean hemoglobin concentration in each red
blood cell. The MCHC is roughly twice the value for hemoglobin
in whole blood and is expressed in the same units. The normal
range is 32 - 36 g/dL. The value is calculated using the
formula, MCHC [in g/dL] = hemoglobin [in g/dL] ÷
hematocrit [in L/L]
- Platelet
Count
refers to the disk shaped structures found in the blood
that have an important function in the coagulation process.
The normal platelet count is between 150,000 and 400,000
mm3. Abnormal bleeding generally occurs when the platelet
count drops below 50,000 mm3, if the platelets are functioning
properly. Bleeding that results from decreased platelets
usually results in small skin hemorrhages or as the oozing
of blood from mucosal surfaces. Screening for proper platelet
function is accomplished by use of the bleeding time test.
Disorders
in the red blood cell count will revolve around either not
enough red blood cells in the blood or too many red blood
cells. The first is called anemia and the second is called
polycythemia. Anemia is a decrease in the red blood cell count,
hemoglobin, and hematocrit. It may be caused by blood loss,
decreased red blood cell production, or an accelerated red
blood cell breakdown.
In
children, one of the most common causes of anemia is the result
of iron deficiency caused by the lack of iron in the child's
diet. Other nutritional anemias, such as deficiencies of vitamin
B-12 or folic acid, are not very common. Another type of anemia
is the result of problems in manufacturing hemoglobin (such
as in sickle cell anemia or thalassemia). Other rare causes
in a low red blood cell count involve patients who have leukemia
or have an abnormality in their bone marrow. Uncommon conditions
that lead to a premature breakdown of red blood cells, such
as spherocytosis or systemic lupus, can also lead to a low
red blood cell count.
Polycythemia
is a condition in which there is an increase in the red blood
cell count, hemoglobin, and hematocrit. Polycythemia can be
classified as either primary or secondary. Secondary polycythemia
is commonly seen in patients who have chronic obstructive
lung disease. Because the patient with COPD lives with chronic
hypoxemia, the bone marrow is stimulated to produce more red
blood cells to help compensate for the lack of oxygen.
Primary
polycythemia is caused by an uncontrolled proliferation of
hematopoietic cells within the bone marrow called polycythemia
vera. Although both types of polycythemia help increase the
oxygen-carrying capacity of the blood, the condition often
places stress on the heart and circulation. This is due to
the increase in the viscosity or thickness of the blood, which
increases the workload on the heart.
White
Blood Cell (WBC) Count
The
white blood cell (WBC) count indicates how many white blood
cells are found in a microliter of whole blood. Strenuous
exercise, digestion of a meal, daily stress, or the presence
of disease can cause the WBC count to fluctuate by as much
as 2000 daily. As a diagnostic tool, WBCs are only useful
when analyzed along with the patients overall health
status and the white cell differential.
The
purposes of WBC Counts are to:
- Identify
the existence of infections or inflammation.
- Determine
whether further diagnostic tests (such as the WBC differential
or bone marrow biopsy) are needed.
- Monitor
the patients response to chemo- or radiation therapy.
Values:
The WBC count can range from 4100 to 10900/microliter.
Interpretation
- Elevated
WBC counts generally signal the presence an infection (i.e.,
an abscess, meningitis, appendicitis, or tonsillitis). Elevated
WBCs can also be caused by leukemia or tissue necrosis caused
by burns, myocardial infarction, or gangrene.
- Low
WBC counts generally indicate bone marrow depression resulting
from viral infections or toxic reactions.
Interfering
Factors
- If
the blood sample is excessively jostled or agitated it can
cause hemolysis, interfering with the accuracy of the test
results.
- If
the patient exercises excessively, is stressed, or is digesting
a meal when the count is taken, it can raise the WBC count,
skewing the accuracy of the results.
- Some
medications can cause the WBC to drop, resulting in inaccurate
results
White
Blood Cell (WBC) Differential
The
WBC differential (relative number of each type of white cell
in the blood) includes information regarding white blood cell
morphology and distribution. It yields more specific data
regarding the immune function than the WBC counts.
The purposes of the WBC differential are to:
- Evaluate
immune capacity regarding infections
- Detect
presence of leukemia
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