Health Assessment – Exam 2
Respiratory – 9
A&P Review
 Bony Structures
 Suprasternal notch
 Sternum
 Manubrium
 Manubrial – sternal angle (Angle of Louis): consistent with 2nd rib
 Xiphoid process
 Costal Angle (<90°): If greater than 90°, that means thicken chest wall (evidence of barrel chest
wall from hypoxia, COPD, etc).
 Landmarks
 Vertebra prominence (C7): base of neck
 Spinous processes
 Inferior angle of scapula
 12th rib
 Anterior, posterior, and midaxillary lines, midsternal line, MCL
 Thoracic Cavity
 Mediastinum
 Esophagus, trachea, heart, great vessels
 Lung borders
 Apices (upper side)
 3-4 cm above clavicle
 Bases
 Rest on diaphragm at 6th rib
 Lobes of the Lungs
 Paired but not symmetric
 Right: shorter 3 lobes
 Left: narrower 2 lobes; no middle lobe
 Anterior: mostly upper/mid lobes
 Posterior: all lower lobes; oblique fissure
 Pleura – forms an envelope
 Parietal: lines chest wall and diaphragm
 Vacuum, negative pressure holds to chest wall. Positive pressure would make them fall.
 Pleurisy (pleuritis – caused by infection, causes painful respirations)
 Trachea and Bronchial Tree
 Trachea
 Anterior to esophagus
 10-11 cm long in an adult
 Bifurcates just below the sternal angle (T4-T5): carina, landmark for trach suction
Right main stem is shorter and straighter
 Implications: If a child swallows a nickel, it goes there. Aspirations in right mid/lower lung
 Bronchial tree
 Protects alveoli from particulate matter
 Goblet cells – traps particles
 Cilia – sweep particles upward
 Acinus
 Bronchioles  alveolar ducts  alveolar sacs  alveoli (grape like cluster)
Function of Respiration
 Supply oxygen
 Remove CO2
 Hypoventilation: increased retention of CO2, slow shallow breathing – causes buildup of CO2 in
 Hyperventilation: blows off CO2, rapid deep breathing, causes CO2 to be blown off
 Maintains homeostasis (pH balance)
 Maintains heat exchange
 Involuntary control of respirations
 In response to cellular demands
 Mediated by the respiratory center in the brainstem
 Pons and medulla
 Major feedback loop is humoral regulation (change in carbon dioxide and oxygen levels in the
blood and the hydrogen ion level (less important)
 Normal stimulus to breathe for most of us is an increase of carbon dioxide in the blood
(hypercapnia). A decrease of oxygen in the blood (hypoxemia) also increases respirations but is
less effective than hypercapnia.
Mechanisms of Respiration
 Inspiration
 Diaphragm flattens, lungs expand, chest size increases
 Vertical and AP diameter increase
 Expiration
 Diaphragm relaxes; dome is up, chest recoils
 Diameters decrease
 Brainstem increase in CO2 (hypercapnia) + decrease in O2 (hypoxemia)  regulates respiratory drive
Subjective Data
 Cough
 Description: hacking, dry, wet, spasmodic (coughing nonstop for minutes), barking
 Sputum (does anything come up?): clear (good), rust (TB/Klebsiella), yellow/green
(bacteria/pseudomonas – CF), pink frothy (pulmonary edema), hemoptysis (blood from lungs, not
blood from chronic irritation of esophagus).
 Timing: night (ex: allergies to bedding), day, location (allergens), meals.
 Relief?
 Associated symptoms? Ex: post ptusive emesis: coughing so hard you vomit
Shortness of Breath (SOB): allergens, orthopnea (difficulty breathing when supine), exercise
intolerance, apnea, PND (paroxysmal nocturnal dyspnea – different breathing at night, sleep in
recliner or propped up)
Chest pain r/t breathing (not necessarily cardiac)
History of frequent acute symptoms?
Chronic lung conditions? Ex: emphysema, TB, cystic fibrosis, allergies, etc.
Unplanned weight changes?
FHx of lung disease?
 Occupational/mask?
 Tobacco?
 Amount (ppd and pack years)
 Duration
 Quit attempts
 2nd hand smoke
Health Promotion
 TB testing: last time, results?
 Smoking cessation
 Lung protection (ex: masks)
 Pneumococcal vaccine and flu vaccine
 Recommended for adults with chronic medical conditions, residents of nursing homes and
group car, health care workers, and those who are immunosuppressed.
Assessment Techniques
 Basic: hands, eyes, ears, stethoscope
 Not necessary for basic patient: PFT, peak flow meter, incentive spirometer, pulse oximeter, x-ray,
MRI, CT, VQ perfusion scan, D-dimer (used to rule out hypercoagulability)
 Thoracic cage – AP : Transverse diameter is 1 : 2
 Shape: pectus excavatum, pectus carinatum (pigeon chest), scoliosis, kyphosis
 Pectus excavatum- hollowed chest is the most common congenital deformity of the anterior wall
of the chest, in which several ribs and the sternum grow abnormally. This produces a caved-in or
sunken appearance of the chest. It can either be present at birth or not develop until puberty.
 Pectus carinatum- opposite of pectus excavatum, characterized by the protrusion of the sternum
and ribs.
 Evidence of scoliosis, kyphosis
 Musculoskeletal can impact breathing; bad curvature impacts lung expansion
 Symmetry
 Unequal chest expansion occurs with marked atelectasis, lobar pneumonia, pleural effusion; with
thoracic trauma, such as fractured ribs or with pneumothorax.
 A lag in expansion occurs with atelectasis, pneumonia, and postoperative guarding.
 Bulging indicates trapped air as in the forced expiration associated with emphysema or asthma.
 Respirations – even, labored? Gasping for breath? Abdominal breathing (normal in children) could
signal respiratory distress in adults.
 Noisy breathing occurs with severe asthma or chronic bronchitis
 Rapid respiratory rates accompany pneumonia, fever, pain, heart disease, and anemia
 Accessory muscles: flaring, grunting, retractions (working extra hard, intercostal muscles pull)
 Body positioning: head bobbing + tripod = respiratory distress
 Facial expressions
 COPD: tense, strained, tired face. Pursed lips in a whistling position – by exhaling slowly and
against a narrow opening, the pressure in the bronchial tree remains positive and fewer airways
 Cerebral hypoxia: excessive drowsiness or by anxiety, restlessness, and irritability.
 hypoxia  altered level of consciousness
 Skin, mucous membrane, nails, nail bed color, and condition
 Nails: blue/purple = bad
 Cold environment could be a factor
 Circumoral cyanosis: blue around mouth
 Acrocyanosis: blue fingers and toes
 Cherry red: due to carbon monoxide poisoning
 Clubbing: nail bed degree is prominent
 Chronic hypoxia: thick, spongy nail bed
Patterns of Respirations
Eupnea: 10-20 breaths per minute
Apnea: stopped breathing for more than 20 seconds
Bradypnea: less than 10 breaths per minute
Tachypnea: more than 24 breaths per minute
Sighing: done occasionally to purposely expand lungs; if done constantly there may be a psych
Hyperventilation (rate/depth)
Hypoventilation: shallow
Cheyne-Stokes (waxe/wane): regular pattern (fast/slow); seen in persons with severe heart failure,
renal failure, meningitis, drug overdose, ICP
 A cycle in which respirations gradually wax and wane in a regular pattern, increasing in rate and
depth and then decreasing.
 Breathing periods last 30-45 seconds, with periods of apnea (20 seconds) alternating the cycle.
 Cycle where see respirations wax/wane in regular pattern- kinda slow, kinda fast
 Consistent with heart failure, renal failure, meningitis, drug overdose, increase intracranial
 Occurs normally in infants and aging persons during sleep
Biot’s (irregular waxe/wane): due to head trauma, brain abscess, heat stroke, encephalitis
 A series of normal respirations (3-4) are followed by a period of apnea.
 The cycle length is variable, lasting anywhere from 10 secs- one minute.
 Seen with head trauma, brain abscess, heat stroke, spinal meningitis, encephalitis
 Symmetric thoracic expansion – around 12th rib
 Asymmetric expansion occurs with diaphragmatic hernia or pneumothorax.
 Tenderness, moisture, lumps, masses
 Tactile fremitus – elicit vibrations (do both sides at the same time)
 Palms, base fingers, ulnar edge of hands
 “99” or “Blue Moon”
 Apices compare bilaterally
 Vibration increases (i.e. pneumonia) with compression or consolidation and decreases with
obstruction (i.e. obstructed bronchus, pneumothorax, emphysema, pleural effusion
 Decreased fremitus: occurs when anything obstructs transmission of vibrations (i.e. obstructed
bronchus, pleural effusion or thickening, pneumothorax, or emphysema). Any barrier that comes
between the sound and your palpating hand will decrease fremitus.
 Increased fremitus: occurs with compression or consolidation of lung tissue (i.e. lobar
pneumonia). This is present only when the bronchus is patent and when the consolidation
extended to the lung surface. Note that only gross changes increase fremitus. Small areas of early
pneumonia do not significantly affect fremitus.
 Rhonchal fremitus: palpable with bronchial secretions
 Pleural friction fremitus: palpable with inflammation of pleura
 Resonance: ICS
 Hyper-resonance: over inflated (i.e. emphysema or pneumothorax)
 Normal for infant or small child; not adults
 Hypo-resonance (dullness): density  Mass? Tumor? Obese?
 Dull (over diaphragm) or flat (over bone)
 Abnormal density in the lungs occurs with pneumonia, pleural effusion, atelectasis, or tumor.
 Lung fields, liver, cardiac borders (anterior)
 Map diaphragmatic excursion (length/movement) with expiration > inspiration = 3-5 cm posteriorly
 Purpose: diaphragm function/movement
 Begin at apices and move down bilaterally every 5 cm
 Avoid scapula and ribs
 Listen for resonance to change into dullness and mark spot
 First: exhale and hold  diaphragm is up
 Second: inhale and hold  diaphragm is down
 High level of dullness and absence of excursion. These occur with pleural effusion (fluid in the
space b/w the visceral and parietal pleural) or atelectasis of the lower lobes.
 Presence
 Note: Clear vs. “don’t hear anything”
 Silent chest means no air is moving in or out, which is an ominous sign.
 Immobile  diminished sounds
 Decreased or absent breath sounds occur:
 When the bronchial tree is obstructed at some point by secretions, mucus plus, or a FB
In emphysema as a result of loss of elasticity in the lung fibers and decreased force of
inspired air; also, the lungs are already hyperinflated so the inhaled air does not make as
much noise.
 When anything obstructs transmission of sound between the lung and your stethoscope,
such as pleurisy or pleural thickening, or air (pneumothorax) or fluid (pleural effusion) in the
pleural space.
 Increased breath sounds occur when consolidation (i.e. pneumonia) or compression (i.e. fluid in
the intrapleural space) yields a dense lung area that enhances the transmission of sound from the
 Symmetry: side to side comparison
 Background noises
 Be careful, hair sounds like rhonchi. Make sure to wet hairy chests with water prior auscultation.
 Normal breath sounds
 Bronchial: tracheal/larynx
 Loud
 Bronchovesicular (toward periphery)
 Major bronchi
 Vesicular
 Peripheral lung fields
 Crackles
 Fine/coarse  rales: sounds like rice krispies
 Moist  rhonchi: sounds like snoring, air movement is turbulent
 Constant or transient  atelectasis: don’t last, not pathologic, disappear after first few breaths
after sleep
 Occur in upper lung fields occur with cystic fibrosis; crackles only in lower fields occur with heart
 Wheeze (easiest to hear)
 Inspiration: signals obstruction
 Ex: child swallows coin; asymmetrical
 Expiration: most common; occurs with lower airway obstruction (i.e. asthma or bronchiolitis).
When unilateral, it may be foreign body aspiration.
 Clears with cough?
 Asthmatic wheezes don’t clear with cough
 Pleural friction rub: coarse, low-pitch, bradding quality (sounds like 2 pieces of leather rubbing)
 Ex: pleuritis
 Stridor: high-pitched inspiratory crowing sound heart without the stethoscope, occurring with upper
airway obstruction (i.e. croup, FB aspiration, or acute epiglottitis).
 Bronchophony: “99”
 Dull vs. clear
 Normal: dull, increased lung density, generated by larynx
 Egophony: “ee-ee-ee”
 “ee” vs. “aa”
 A  areas of consolidation (i.e. pneumonia)
 Whispered pectoriloquy
 Dull vs. clear
 Normal: dull
 Infants and Children
 Surfactant: surface tension, lipid substance needed to inflate alveoli, produced at 32 weeks
gestation. Premature babies need exogenous/artificial surfactant because they cannot expand
their lungs.
 70 million alveoli (vs. 300 million in adults)
 Increased risk if exposed to irritants such as second hand smoke
 Cutting cord activates respirations via change in circulation from adult to fetus
 Inspect (similar to adult)
 Shape and symmetry
 Rounded thorax/belly
 Barrel shape persisting after age 6 years, which may develop with chronic asthma or
cystic fibrosis.
 Harrison’s groove occurs normally, but also occurs with rickets from the pull of the
diaphragm on weakened ribs.
 Ribs/xiphoid prominent (especially if they’re skinny)
 Apgar score (3-6 is moderate; 0-2 indicates a several depressed newborn needing full
resuscitation, ventilation assistance, and subsequent intensive care)
 Appearance
 Pulse
 Grimace (reflex irritability)
 Respiratory effort
 Muscle tone
 Palpate: look for lumps, masses, crepitus (especially over clavicle if fractured at birth)
 Crepitus: coarse, crackling sensation palpable over the skin surface. It occurs in subcutaneous
emphysema when the air escapes from the lungs and enters the subcutaneous tissue, as
after open thoracic injury or surgery.
 Palpable around fracture clavicle, which may occur with difficult forceps delivery
 Percussion will be hyper-resonant (normal), limited usefulness – auscultation is better.
 Obligate nose breathers 3 months; they don’t know how to breath out of their mouth until then
 Abdominal breathing (vs. thoracic in adults)
 Respiration rate: 30-40+ (listen for full minute b/c irregular)
 Bronchovesicular sounds until 5-6 years
 Fine crackles immediate new period because opening lungs for first tie
 Note: When listen to pediatric patients, if you hear wheezing or rhonchi – don’t stop. Next put
the stethoscope over the nose/mouth and compare the sounds. If they’re the same, signals upper
respiratory congestion moved to lungs. This is not a problem. Everything is magnified in peds.
 Tachypnea of 50-100 per minute in infants during sleep may be an early sign of heart failure.
 Pregnancy
 Wider thorax
 Deeper respirations
 Elevated diaphragm
 Increased total circumference
 Increased tidal volume
 Increased awareness of need to breathe
 Aging
 Rigid thorax: poor chest expansion
 Decreased vital capacity
 Prone to atelectasis
 Acute respiratory failure  barrel chest (thickened chest wall; greater than 90 degrees costalsternal angle)
 Kyphosis (impacts breathing)
 Easily fatigued, during tests – don’t rush causing them to hyperventilate
 Decreased chest expansion
 Increased risk post-op complications due to decreased lung expansions
Pleural Effusion
Free air in pleural space causes
partial or complete lung collapse. Air
in pleural space neutralizes the usual
negative pressure present; thus lung
collapses. Usually unilateral.
Pneumothorax can be:
1) Spontaneous: air enters pleural
space through rupture in lung wall.
2) Traumatic: air enters through
opening or injury in best wall.
3) Tension: trapped air in pleural
space increases compressing lung
and shifting mediastinum to the
unaffected side.
Collection of excess fluid in the
intrapleural space, with compression
of overlying lung tissues. Effusion
may contain watery capillary fluid
(transudative), protein (exudative),
purulent matter (empyemic), blood
(hemothorax), or milky lymphatic
fluid (chylothorax). Gravity settles
fluid in dependent areas of thorax.
Presence of fluid subdues all lung
I: unequal chest expansions. If large,
tachypnea, cyanosis, apprehension,
bulging in interspaces.
Pal: Tactile fremitus decreased or absent.
Tracheal shift to opposite side (unaffected
side). Chest expansion decreased on
affected side. Tachycardia, decreased Bp.
Per: hyperresonant. Decreased
diaphragmatic excursion.
A: Breath sounds decreased or absent.
Voice sounds decreased or absent.
I: Increased respirations, dyspnea; may
have dry cough, tachycardia, cyanosis,
abdominal distention.
Pal: Tactile fremitus decreased or absent.
Tracheal shift away from affected side.
Chest expansion decreased on affected
Per: Dull to flat. No diaphragmatic
excursion on affected side.
A: Breath sounds decreased or absent.
Voice sounds decreased or absent. When
remainder of lung is compressed near the
effusion, may have bronchial breath
sounds over the compression along with
bronchophony, egophony, whispered
I: During severe attack  increased resp.
rate, SOB with audible wheeze, use of
accessory neck muscles, cyanosis,
apprehension, retraction of intercostal
Allergic hypersensitivity to certain
inhaled allergens (ex: pollen),
irritants (ex: tobacco, ozone),
microbes, stress, or exercise that
produces a complex response
wheezing on
inspiratory and
Cystic Fibrosis
characterized by bronchospasm and
inflammation, edema in walls of
bronchioles, and secretion of highly
viscous mucus into airways. These
factors greatly increase airway
resistance, especially during
expiration, and produce symptoms
of wheezing, dyspnea, and chest
Proliferation of mucus glands in the
passageways, resulting in excessive
mucus secretion. Inflammation of
bronchi with partial obstruction of
bronchi by secretions or
constrictions. Sections of lung distal
to obstruction may be deflated.
Bronchitis may be acute or chronic
with recurrent productive cough.
Chronic bronchitis is usually caused
by cigarette smoking.
Infection in lung parenchyma leaves
alveolar membrane edematous and
porous, so RBCs and WBCs pass from
blood to alveoli. Alveoli progressively
fill up (become consolidated) with
bacteria, solid cellular debris, fluid,
and blood cells, which replace
alveolar air. This decreases surface
area of the respiratory membrane,
causing hypoxemia.
Inhalation of tubercle bacilli into the
alveolar wall starts:
1) Initial complex is acute
inflammatory response –
macrophages engulf bacilli but do
not kill them. Tubercle forms around
2) Scar tissue forms, lesion calcifies,
and shows on x-ray.
3) Reactivation of previously healed
lesion. Dormant bacilli now multiply,
producing necrosis, cavitation, and
caseous lung tissue (cheeselike).
4) Extensive destruction as lesion
erodes into bronchus, forming airfilled cavity. Apex usually has most
spaces. Expiration labored, prolonged. If
chronic, may have barrel chest.
Pal: Tactile fremitus decreased,
Per: Resonant. If chronic, may be
A: Diminished air movement. Breath
sounds decreased, with prolonged
expiration. Voice sounds decreased.
I: hacking, rasping cough productive of
think mucoid sputum. Chronic  dyspnea,
fatigue, cyanosis, possible clubbing of
Pal: Tactile fremitus is normal.
Per: Resonant
A: Normal vesicular. Voice sounds normal.
Chronic  prolonged expiration.
I: Increased resp. rate. Guarding and lag on
expansion on affected side.
In children – sternal retraction, nasal
Pal: chest expansion decreased on
affected side. Tactile fremitus increased if
bronchus patent, decreased if bronchus
Per: Dull over lobar pneumonia.
A: breath sounds louder with patent
bronchus, as if coming directly from larynx.
Voice sounds have increased clarity;
bronchophony, egophony, whispered
pectoriloquy present. In children –
diminished breath sounds may occur early
in pneumonia.
Usually asymptomatic, showing as positive
skin test or x-ray. Progressive TB involve
weight loss, anorexia, easily fatigued, lowgrade afternoon fevers, night sweats. May
have pleural effusion, recurrent lower
respiratory infections.
I: cough initially nonproductive, later
productive of purulent, yellow-green
sputum, may be blood tinged. Dyspnea,
orthopnea, fatigue, weakness.
Pal: Skin moist at night from night sweats.
Per: Resonant initially. Dull over any
A: Normal or decreased vesicular breath
Crackles – fine
to medium.
Crackles over
deflated areas.
May have
Crackles over
upper lobes
following full
expiration and
Heart Failure
Pump failure with increasing
pressure of cardiac overload causes
pulmonary congestion or an
increased amount of blood present
in pulmonary capillaries. Dependent
air sacs are deflated. Pulmonary
capillaries engorged. Bronchial
mucosa may be swollen.
Destruction of pulmonary connective
tissue (elastin, collagen);
characterized by permanent
enlargement of air sacs distal to
terminal bronchioles and rupture of
interalveolar walls. This increases
airway resistance, especially on
expiration – producing a
hyperinflated lung and an increase in
lung volume.
*cigarette smoking accounts for 8090% of emphysema cases.
I: Increased resp. rate, SOB on exertion,
orthopnea, paroxysmal nocturnal dyspnea,
nocturia, ankle edema, pallor in lightskinned people.
Pal: skin moist, clammy. Tactile fremitus
Per: Resonant.
A: Normal vesicular. Heart sounds include
S3 gallop.
I: increased AP diameter. Barrel chest. Use
of accessory muscles to aid respiration.
Tripod position. SOB, esp. on exertion. RD.
Pal: decreased tactile fremitus and chest
Per: Hyperresonant. Decreased
diaphragmatic excursion.
A: Decreased breath sounds. May have
prolonged expiration. Muffled heart
sounds resulting from overdistention of
Cardiovascular – 13
A&P Review
 Structures
 Endocardium
 Myocardium: muscular, “pumper”
 Pericardium: fibrous, protective
 Positioning
 Mediastinum: center of chest wall
 Base: at the top
 Apex: at the bottom left
 5th ICS L. MCL
 Can change (i.e. in peds it may be in 4th ICS)
 Dextracardia: things are flipped; heart is on right side
 Blood Flow
Crackles at lung
Usually none,
 Cardiac Output
 CO = HR x SV (amount of blood pumped by LV in one contraction)
 Preload: filling/relaxation
 Afterload: contraction
 Conduction system (ventricular innervations)
 SA node  AV node  Bundle of His  R/L bundle branches
 PHx
 Cardiac disease/surgeries?
 FHx
 CVD? Who? What Age?
 Ex: PGF died at 42 from acute MI
 Congenital (ex: atrial septal defect) or acquired disease (rheumatic fever)?
 HTN? Obesity? DM? CAD? Sudden death at younger age?
 SHx
 Habits?
 Smoking, drinking, poor nutrition, activity, occupation (ie: desk job = no activity)
 Non-modifiable risks for heart disease: FHx, gender, age, genetics
 Modifiable risks: lifestyle, diet, exercise
 Risk factors for CAD: elevated cholesterol and BP, blood sugar levels above 130 mg/dL or DM,
obesity, cigarette smoking, low activity level, and length of any hormone replacement therapy for
postmenopausal women.
 Meds?
 Cardiac meds, antihypertensives, or med w/ cardiac side effects
 Chest pain? PQRSTU
 Palliative: stop movement, rest, nitroglycerine / provocative: exertion, stress
 Quality: male vs. female
 M: “Feels like an elephant sitting on chest” crushing/squeezing feeling
 F: pain in jaw, back of neck, and arm; nausea/vomiting
 Region and radiation: jaw, shoulder
 Severity
 Timing: When did it start? What were you doing?
 Understanding patient’s perspective: What do you think happened?
 Associated symptoms: diaphoresis, vomit, nausea
 Acute MI: necrosis of heart cells
 Peripheral
 Leg pain/cramp with or without activity? Distance?
 Claudication – could be intermittent; cramping pain in the leg is induced by exercise,
typically caused by obstruction of the arteries.
 Skin changes or hair loss on feet or legs?
 Ex: DM with peripheral artery disease  no walking barefoot
 PAD: thin, shiny skin with no hair. Nails are very thick/deformed. No good circulation.
 Palpitations: possible due to caffeine
 Dyspnea [on exertion (DOE)]: out of breath
 Paroxysmal nocturnal dyspnea (PND) occurs with heart failure. Lying down increases volume
of intrathoracic blood, and the weakened heart cannot accommodate the increased load.
Typically, the person awakens after 2 hours of sleep with the perception of needing fresh air.
 Orthopnea: difficulty breathing laying flat  use pillows or recliner
 Cough?
 Hemoptysis is often a pulmonary disorder but also occurs with mitral stenosis.
 Fatigue?
 R/T decreased CO is worse in the evening.
 Cyanosis or pallor?
 Occur with MI or low CO as a result of decreased tissue perfusion.
 Edema?
 Dependent when caused by heart failure, worse in the evening and better in the morning
after elevating legs all night, bilateral (unilateral swelling has a local vein cause)
 Nocturia? Getting up at night to pee (i.e. congestive heart failure)
Health promotion
BP checks
Cholesterol screening
 DASH diet
 Fat intake
 Precordium/Chest Wall
 Inspect
 Heaves or lifts: indicates over activity; look at apex area in the left sternal border
 Hyperdynamic precordium or active precordium which signals left ventricular
hypertrophy (LVH)
 LVH: diffused left lifting pulse
 Palpate
 Thrills: palpable vibration at PMI, apex impulse, apical pulse, 5th ICS MCL. Feels like throat of a
purring cat – turbulent blood flow.
 Heave + thrill = murmur (must auscultate)
 Carotid Artery
 Carotid sinus hypersensitivity is the condition in which pressure over the carotid sinus
leads to a decreased heart rate and BP, and cerebral ischemia with syncope. The may
occur in older adults with hypertension or occlusion of the carotid artery.
 Apical Pulse
 Note location, size, amplitude, and duration
 LV dilation displaces impulse down and to the left and increases size more than one
 A sustained impulse with increased force and duration but no change in location occurs
with LV hypertrophy and no dilation (pressure overload)
 Not palpable with pulmonary emphysema due to overriding lungs.
 Percuss (limited usefulness)
 Size and location (not children or obese)
 Cardiomegaly d/t increased ventricular volume or wall thickness; it occurs with HTN, CAD,
heart failure, and cardiomyopathy.
 Auscultate (5 locations): Aortic, Pulmonic, Erb’s point (where all sounds come together midpoint), Tricuspid, Mitral  APE To Man
 Auscultate Systematically
 Sitting then lying; then left side-lying to bring the heart more superficial to hear the extra
heart sounds better.
 Diaphragm then bell
 Note: rate (reg x2 or full minute) and rhythm
 S1 and S2 (first), S3 and S4 if applicable
 Murmurs
 Pulse deficit - get apical and then radial pulse
 Signifies a weak contraction of the ventricles; it occurs with atrial fibrillation, premature
beats, and heart failure.
 Apical – radial = 6 to 10
 Numbers should be close – if greater than 6 to 10  pulse deficit and signifies AF
 Pericardial friction rub (pericarditis)
 Scratchy, rough, grading
 LLSB or apex
 Leans forward
 When auscultating, ask patient to hold breath after expiration to cut out respiratory
Heart Sounds
 Closure of valves
 Turbulence of blood flow
 First heart sound: S1
 “Lub”
 Closure of AV valve
 Systole begins
 Best heard at the apex
 Second heart sound: S2
 “dub”
 Closure of semilunar (aortic and pulmonic) valves
 Systole ends
 Best heard at base
Diminished S1 and S2 d/t condition that place an increased amount of tissue between the heart and
your stethoscope: emphysema (hyperinflated lungs), obesity, and pericardial fluid.
Split S2
 S2 is supposed to be one sound, but sometimes splits because aortic valve closed before the
 Effect of respirations and pressure gradients: Ask patient to take “deep deep breaths” and if the
pressure gradient remains constant or fix that is no bueno.
 Fixed split is unaffected by respirations.
 Paradoxical split is where the sounds fuse on inspiration and split on expiration.
S3 – pathologic
 Ventricular gallop
 Vibration due to rapid ventricular filling
 Occurs after S2 due to volume (fluid) overload, softer
 Sounds like “Kentucky” or “Slosh-ing-in” (rare)
 Low pitch – use bell of stethoscope
 First sign for CHF
S4 – pathologic
 Atrial gallop
 Atria contract and push blood into non-compliant ventricle; soft sound
 Occurs presystole (before S1)
 Sounds like “Tennessee” or “A-stiff-wall”
 Low pitch  use bell at apex
 AMI? Ominous sign
All 4 heart sounds = train wreck
Bruits and Hums
 Abnormal in adults – extra heart sounds (i.e. in atherosclerosis)
 Palpate 1 side at a time and auscultate with bell for carotid bruits (=S1)
 Venous hum in supraclavicular fossa = normal in children due to turbulence in jugular venous
 Turbulent blood flow resulting in blowing or swooshing sound
 Causes:
 Increased velocity (i.e. increased heart rate – when children have an acute illness, exercise,
 Decreased viscosity (i.e. anemia or sickle cells)
 Structural defects
 Prolapse (incompetent)
 Stenosis (narrowing)
 Defective opening: “leaky pipe”
 Unusual openings in the chambers (dilated chamber, wall defect)
 Can hear better in thinner patients
 Can’t hear as well with obese, muscular, or fluid (due to CHF) filled patients.
 Functional (not pathological) Murmurs
 Common in kids
 Increased blood force and velocity against a thin chest wall
 “Still’s” murmur = innocent murmur
 More pronounced with a child who has fever, anemia, or supine
 5 Ways to Describe Murmurs
 Loudness
 Grade I/VI: barely  go undiagnosed
 II/VI: faint
 III/VI: moderate
 IV/VI: loud  feel thrills
 V/VI: very loud
 VI/VI: can be felt touching the skin and can hear it without a stethoscope.
 Region and Radiation: localized? Radiate?
 Pitch: High/Low?
 Timing: when do you hear it?
 Systole or diastole
 Crescendo
 Decrescendo
 Pan/Holo: entire S1 or S2? Or just one short portion of S1 or S2?
 End/Mid
 Quality
 Blowing
 Harsh
 Rumble: like train, especially if S1 or S4
Jugular Venous Distension (JVD)
 Supine with HOB 30-45° (no pillow). Use tangential lighting over neck and ask patient to look away;
external jugular pulse should be visible.
 Top of the waveform of the internal jugular venous pulsation = height of the venous distention
 Imaginary horizontal line (parallel to the floor) is then drawn from this level to above the sternal
 Use 2 rulers
 First ruler goes on the Angle of Louis
 2nd ruler goes from height of EJV parallel to the floor.
 Find the number that’s vertical where the rulers intersect and that’s the JVD.
 More than 4-5 cm from sternal angle to imaginary line = elevated venous pressure  CHF
Heptojugular Reflux (HJR)
Supine with HOB at 45° angle
Mouth open, breathes normally
Moderate pressure is applied over the middle or RUQ abdominal region for 30-60 seconds
Height of the neck veins increases by at least 3 cm and the increase is maintained throughout the
compression period  HJR
 Look for distention
 Greater than 3cm = compromised circulation
 Sites (arteries)
 Temporal, carotid, aorta, brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, posterior tibialis
 Description
 0 absent
 1+ weak
 2+ normal
 3+ increased
 4+ bounding
Weak, Thready, 1+
Full, bounding, 3+
Water Hammer
(Corrigan), 3+
Pulsus Bigeminus
Pulsus Alternans
Pulsus Paradoxus
Pulsus Bisferiens
See page 519 for visual
Associated With
Hard to palpate, need to search Decreased cardiac output, peripheral
for it, may fade in and out,
arterial disease, aortic valve stenosis
easily obliterated by pressure.
Easily palpable, pounds under
Hyperkinetic states (exercise, anxiety,
fever), anemia, hyperthyroidism
Greater than normal force, then Aortic valve regurgitation, patent ductus
collapses suddenly
Rhythm is coupled, every other Conduction disturbance (i.e. premature
beat comes early, or normal
ventricular contraction, premature atrial
beat is followed by premature
contraction, dysrhythmia).
beat. Force of premature beat
is decreased because of
shortened cardiac filling time.
Rhythm is regular, but force
When HR is normal, pulsus alternans
varies with alternating beats of occurs with severe left ventricular
large and small amplitude
failure, which in turn is due to ischemic
heart disease, valvular heart disease,
chronic hypertension, cardiomyopathy,
or CHF
Beats have weaker amplitude
A common finding is cardiac tamponade
with inspiration, strong with
(pericardial effusion in which high
expiration. Best determined
pressure compresses the heart and
during blood pressure
blocks cardiac output); also in severe
measurement; reading
bronchospasm of acute asthma
decreases (> 10 mmHg) during
inspiration and increases with
Each pulse has two strong
Aortic valve stenosis plus regurgitation,
systolic peaks, with a dip in
between. Best assess at carotid
 Temperature
 Is there a difference between R/L?
 Sores or lesions
 Edema
 Measure bilat
 Pitting: 1+ (mild)  4+ (deep)
 Color
 Pallor
 Rubor – red
 Cyanosis – blue
 Brawny (v. stasis) – brown
 Varicosities
 Auscultate for bruits over abdomen
 Pincer grasp for AAA (abdominal aortic aneurysm)
 Pregnancy
 Increase HR, blood volume (by 30-40%), cardiac output
 Edema
 Varicosities r/t decrease in arterial pressure
 BP lowest 2nd trimester then increases (especially in 3rd trimester)
 Preeclampsia: pregnancy induced hypertension (PIH)
 Lie left lateral to decrease BP due to oxygenation
 PIH: Greater than 30 mmHg increase systolic or greater than 15 mmHg increase diastolic
 Aging
 Lifestyle (smoking, diet, alcohol, exercise and stress)
 Increased systolic BP d/t stiffening of large arteries  arteriosclerosis  difficulty feeling pulses
 Left ventricular wall thickens  increased workload
 Decreased response to exercise (orthostasis)
 Increased incidence arrhythmias and ectopic beats
 S3 is associated with heart failure and is ALWAYS abnormal over age 35.
 Infant
 Initial murmurs
 PDA – patent ductus arteriosis
 10-15 hours after birth, mixing arterial and venous blood
 PFO – patent foramen ovale
 1 hour after birth
 Treatment: meds or surgery
 Truncus arteriosis + Transposition of Great Vessels  emergency d/t no oxygenated blood
 Coarctation of aorta
 Tetraology of Fallot
 Stenosis
 HR 1 minute
 R = L ventricle size to 1 year and then L:R is the same as adult 2:1
 Positioned horizontal with apex at 4th ICS
 1 umbilical vein, 2 umbilical arteries
 Cyanosis at or just after birth signals oxygen desaturation of congenital heart disease.
 Important signs of heart failure: persistent tachycardia (>200 in newborns, >150 in infants),
tachypnea, liver enlargement, engorged veins, gallop rhythm, and pulsus alternans.
 Respiratory crackles (rales) are an important sign in adults, but not in infants.
 Apex displacement r/t
 Cardiac enlargement  shift to the left
 Pneumothorax  shifts away from affected side
 Diaphragmatic hernia  shifts usually to the right b/c this heart occurs more often on the
 Dextrocardia (a rare anomaly in which the heart is located on the right side of the chest)
 Diagnostics
 Holter – 24 hr EKG
 Ambulatory BP
 EST – exercised stress test
 Chemical stress test – injection
 Echocardiogram – ultrasound of heart
 Angiography – note any areas of blockages
 Cardiac enzymes – lab test to rule out MI
 Allen test – radial and ulnar artery patency
 The hand is elevated and the patient/person is asked to make a fist for about 30 seconds.
 Pressure is applied over the ulnar and the radial arteries so as to occlude both of them.
 Still elevated, the hand is then opened. It should appear blanched (pallor can be observed at
the finger nails).
 Ulnar pressure is released and the color should return in 7 seconds.
 If color does not return or returns after 7–10 seconds, the test is considered negative and the
ulnar artery supply to the hand is not sufficient. The radial artery therefore cannot be safely
 Homan’s Test – rule out deep vein thrombosis (DVT)
leg circumference, >1 cm difference
Ankle/Brachial Index (ABI): < 0.9 = PVD)
Doppler A/V
 Causes
 Valvular disease
 Thyroid disease
 S/S
 Skin-ashen, diaphoretic
 SOB/DOE, orthopnea, paroxysmal nocturnal dyspnea (PND)
 Crackles
 Hypotension
 Edema, ascites
 Nausea/vomiting
 Anxiety
 Change in level of consciousness
 S3, tachy, deviated PMI
 Decreased urinary output
Gastrointestinal – 15
Karen c/o abdominal pain
P: What brought on the pain?
Q: How does it feel? Sharp, stabbing, dull?
R: Region or radiation
S: Scale out of 1 to 10
T: How long does it last? When does it occur?
U: What do you think it means?
 Subjective
 Weight changes? Is it planned? Diet?
 Anorexia: in elderly, loss of appetite (not psychiatric)
 Could be r/t GI disease, pregnancy, or psychological
 Appetite?
 Dysphagia?
 Difficulty swallowing – solids? Liquids?
 Seen in disorders of the throat/esophagus
 Food intolerance?
 Ex: lactose intolerance (common in Asians) (50% of Mexican Americans and 80% of AA)
 Symptoms: what can you tolerate? What happens? Do you use antacids?
 Is there belching (eructation), bloating, heart burn?
 Abdominal pain
May be visceral from an internal organ (dull, general, poorly localized); parietal from
inflammation of overlying peritoneum (sharp, precisely localized, aggravated by movement);
or referred pain.
 Acute pain requiring urgent diagnosis occurs with appendicitis, cholecystitis, bowel
obstruction, or a perforated organ.
 Chronic pain of gastric ulcers occurs on an empty stomach, pain of duodenal ulcers occurs 23 hours after a meal and is relieved by more food.
 Frequency? Timing?
 Hematemesis: bloody vomit; occurs with stomach or duodenal ulcers and esophageal varices.
 Associated symptoms?
 Colicky pain, diarrhea, fever?
 R/T food poisoning, GI disease, meds, and early pregnancy
Bowel habits
 Frequency? Constipation?
 Color: black stools may be tarry due to occult blood (melena) from GI bleeding or non-tarry
from iron medications. Gray stools occur with hepatitis.
 Consistency? Any bleeding?
 Changes
 Bleeding
 Hematochezia (frank) – lower GI  bright blood (i.e. hemorrhoid)
 Melena or tarry (occult) – upper GI  dark blood
PHx? Surgeries related to GI system? (i.e. appendectomy, cholestectomy)
FHx? CA, polyps, IBD, IBS
 Antacids (i.e. pepto)
 NSAIDS r/t peptic ulcer disease
 FE+ (cause constipation)
 ETOH (alcohol) – ask how much is consumed
Hemorrhoids – when people have enlarged veins in the rectum
Pruritis ani – anal itching (could be caused by hemorrhoids or coffee, tea, and citrus can irritate
the anus)
Fistulas – abnormal passageway between organs and vessels
 Ex: tunnel between anal gland and access on skin.
Nutritional assessment: What are they eating? 24 hour diet recall is important.
 Tobacco? ETOH? Caffeine?
 Infants/Children
 Breast milk vs. formula
 Whole milk at 1 year
 Introduction to solid foods – what age?
 Fe+ formula supplement
 Pica: when children eat nonfoods like dirt and grass
 Teens
 Eating patterns: regular meals? Snacks? Junk food?
 Exercise habits? Exercise is often hyperactive.
 Body image: “What/how do you think your body looks like?”
 Anorexia nervosa: patient refuses to maintain body weight; extreme fear of gaining weight.
 Boys need 4000 cal/day, girls need 20% less
 Aging Adults
 Pernicious anemia: vitamin B12 due to lack of intrinsic factor.
 Weight changes – start to lose weight
 Bowel preoccupation: ask about bowel patterns, constipation, and fluid/fiber intake.
 Achalasia
 Decreased esophageal peristalsis and LES constriction: esophagus becomes weak and is less
able to transport food. Esophageal emptying is delayed, and if fed in a supine position –
increased risk for aspiration.
 Dysphagia  constipation r/t lack of liquid
 Constipation is caused by decreased physical activity, inadequate intake of water, a lowfiber diet, side effects of meds, IBS, bowel obstruction, hypothyroidism, and inadequate
toilet facilities.
 Salivation decreases, causing a dry mouth and a decreased sense of taste
 Pregnancy
 N/V r/t hormone changes
 Heart burn (pyrosis) r/t esophageal reflux
 Decreased gastric motility  constipation and hemorrhoids
 Bowel sounds are diminished
 Patient preparation:
 Have adequate lighting to visualize abdomen
 Empty bladder to listen (Specimen?)
 Warm room, stethoscope, and hands
 Cold hands = tensing
 Abdomen: supine with knee bent
 Rectal:
 Male: Left lateral recumbent or standing forward flexed
 Female: Left lateral or lithotomy
Epigastrum, Hypogastrum (Suprapubic), Periumbilical
 RUQ: liver gallbladder, duodenum, head of pancreas, right kidney & adrenal gland, hepatic flexure of
colon, part of ascending colon and transverse colon.
 LUQ: Stomach, spleen, left lobe of liver, body of pancreas, left kidney & adrenal gland, and splenic
flexure of colon, part of tranverse and descending colon
 RLQ: Cecum, appendix, right ovary and tube, right ureters, and right spermatic cord
 LLQ: Part of descending colon, sigmoid colon, left ovary and tube, left ureter, and left spermatic cord.
 CVA: costovertebral angle
 Retroperitoneal
Inspect  Auscultate  Percuss  Palpate
 Demeanor
 Relaxed vs. agitated
 Abdomen
 Contour
 Scaphoid: concave
 Flat
 Rounded
 Protuberant
 Distended (convex)
 Fat
 Fluid (ascites)
 Flatus: gas
 Feces
 Fetus
 Fatal (malignancy): cancer
 Fibroids
 Pulsations: may see aortic in thin people (normal)
Marked pulsation occurs with widened pulse pressure (i.e. HTN, aorta insufficiency,
thryrotoxicosis) and aortic aneurysm.
 Waves of peristalsis: marked visible peristalsis with a distended abdomen indicated intestinal
 Skin: Lesions/rash/color/scars
 Striae: stretch marks (d/t rapid weight gain, pregnancy, ascites); look purple-blue with
Cushing syndrome.
 Color
 Redness: localized inflammating
 Jaundice
 Skin glistening and taut  ascites
 Cutaneous angiomas (spider nevi) occur with portal hypertensions or liver disease.
 Prominent, dilated veins occur with portal hypertension, cirrhosis, ascites, or vena cava
obstruction. Veins are more visible with malnutrition as a result of thinned adipose tissue.
 Poor turgor accompanies GI disease and occurs with dehydration.
 Symmetry: should be symmetric bilaterally
 Bulges? Masses? Hernia – protrusion of abdominal viscera through abnormal opening in
muscle wall.
 Umbilicus
 Everted with ascites or underlying mass.
 Deeply sunken with obesity.
 Enlarged, everted with umbilical hernia
 Bluish periumbilical color occurs with intra-abdominal bleeding (Cullen sign)
 Rectal
 Anal fissures
 Hemorrhoids
 Rectal discharge
 Prolapse
 Papilloma (condyloma): warts caused by HPV
 Imperforate anus: no anus
 After birth, the meconium (first poop) must be defecated, and in IA it can’t. Surgery required.
 Bowel Sounds (BS)
 Press lightly with warmed diaphragm
 All 4 quadrants
 begin RLQ (ileocecal) then go clockwise
 BS always here normally
 Note: Character & Frequency
 Normal (5-30x/min)
 Hyperactive: loud, high-pitched, rushing, tinkling sounds that signal increased motility.
 Borborygmus, stomach growling
 Hypoactive or absent: follow abdominal surgery or with inflammation of peritoneum
 Absent (0 x5’) have to listen for 5 minutes in each quadrant to be able to say that.
 Vascular Sounds
 Press more firmly
 Vascular Sounds
 Bruits (normal in children) heard in patients with heart failure and hypertension.
 All 4 quads
 Tympany predominates; dull = solid
 Dulls occurs over distended bladder, adipose tissue, fluid, or a mass.
 Hyperresonance is present with gaseous distention.
 Liver Span, resonance to dull. Then tympany to dull; typical 6-12 cm  enlarged liver span
indicates hepatomegaly.
 Percuss CVAT - direct or indirect. Should not be tender – sharp pain occurs with inflammation of the
kidney or paranephric area.
 Percuss splenic dullness – 9-11th ICS L MAL
 A dull note forward of midaxillary line indicates enlargement of the spleen, as occurs with mono,
trauma, and infection.
 A change in percussion from tympany to a dull sound with full inspiration is a positive spleen
percussion sign, indicating splenomegaly. This method will detect mild to moderate
enlargement before spleen becomes palpable as in mono, malaria, and hepatic cirrhosis.
 Special procedures
 Fluid wave test (to differentiate ascites from gaseous distention)
 S/S: distended abdomen, bulging flanks, and an umbilicus that is protruding and displaced
 Ascites occurs with heart failure, portal HTN, cirrhosis, hepatitis, pancreatitis, and CA.
 Shifting dullness
 Positive with a large volume of ascitic fluid; it will not detect less than 500 mL of fluid.
 Palpate for: enlargements and masses
 Note: Size, location, shape, consistency, surface, mobility, pulsatility, tenderness, guarding,
rigidity, and masses.
 Involuntary rigidity is a constant, board-like hardness of the muscles. It is a protective
mechanism accompanying acute inflammation of the peritoneum. It may be unilateral, and
the same area usually becomes painful when the person increases intra-abdominal pressure
by attempting a sit up.
 Tenderness occurs with local inflammation, inflammation of the peritoneum or underlying
organ, and with an enlarged organ whose capsule is stretched.
 Nephroblastoma: tumor in kidney (Wilm’s); non-tender mass; DO NO PALPATE
 6 % of all childhood cancers
 Light then Deep 1cm > 5-8cm
 Use palmar surface fingers; clockwise motion around abdomen
 Bimanual technique
 Use in patients with large abdomen (obesity)
 Retroperitoneal organs
 Liver (GB)
 Bimanual technique
 Duck bill: used to palpate liver 1-2 cm below costal margin
 Alternative Hooking Technique to palpate the lower margin of liver
 Murphy’s sign: “take a deep breath”
 Inspiration depresses liver/GB for palpation under costal margin
 When test positive, as the descending liver pushes into the inflamed gallbladder onto the
examining hand, the person feels sharp pain and abruptly stops inspiration midway.
 Aorta
 Palpate just to L of umbilicus w/ opposing fingers
 Normal= 2.5 to 4 cm wide
 “AAA” Abdominal Aortic Aneurysm: aorta develops weakness and becomes enlarged.
 Kidneys/Adrenal
 Bimanual (AP) technique
 Slide hands laterally
 May palpate R lower pole
 No changes felt with deep inspiration
 Spleen
 Bimanual AP, left hand on the left side of 11th to 12th rib.
 Ask patient to take a breath
 Only palpable when 3x normal size
 Spleen enlarges with mononucleosis, trauma, leukemias, and lymphomas. A large spleen
is friable and can rupture easily with over palpation.
 Roll side lying right
 Palpation Hints
 “I’m going to inspect this now.”
 Tender area last
 Voluntary guarding vs. involuntary rigidity
 Keep Knees bent
 Ticklish? Do self-palpation and join them
 Anus, Rectum & Prostate
 Position:
 lateral recumbent (L side/R knee flexed)
 Dorsal lithotomy
 Forward over table
 Anus
 Check sphincter tone (anal wink)
 Gloved index finger w/ lubricant
 Check for hemorrhoids (int/ext)
 Prostrate
 Valsalva; when they take a deep breath, bear down, and check prostate.
 Prostate @ 2.5x4 cm
 Smooth
 Rubbery
 Non-tender
 Heart shaped
 Check for masses
 Rectum
 Examine stool
 Color/consistency
 Guaiac-occult blood: testing for blood in the stool
 Abnormal:
 Jelly-inflammation (i.e. when one intestine telescopes into another)
 Bright red (hematochezia)-lower GI
 Tarry (melena) DARK- upper GI
 Black-Fe+, Pepto
 Gray/tan-hepatobilliary
 Greasy/fatty-malabsorption
 Called steatorrhea
Developmental Changes
 Infants/Children
 Umbilical = 2A 1V
 Jelly stool (intussuception)
 Large liver & most organs palpable
 For years and younger: Protuberant (pot belly)  sitting/lying
 After four: flat  laying supine.
 BS only, no vascular sounds on auscultation; don’t percuss over spleen
 Diastasis recti: separation of rectus muscles with a visible bulge along the midline; normal
variation; more common in black infants – refer if it lasts more than 6 years.
 Umbilical hernia appears 2-3 weeks, reaches maximum size at 1 month, and disappears by 1 year.
 Refer any umbilical hernia larger than 2.5 cm, one that continues to grow after 1 month, or
one lasting more than 2 years in a white baby and more than 7 years for a black baby.
 Scaphoid abdomen in a child is associated with dehydration or malnutrition.
 Younger than 7 years, the absence of abdominal respirations occurs with inflammation of the
 Aging Adult
 Inc. fatty deposits abdomen and hips
 Muscle atrophy = organs easily palpable
 liver can be lower, kidneys easy to palpate
 Referred Pain
Special Procedures
 Rebound tenderness?
 Peritonitis accompanied with appendicitis (Blumberg’s sign) palpate at 90 degree angle at
opposite side of pain.
 “Karate chop” Normal response: no pain at the release of pressure
 Pain on release of pressure confirms rebound tenderness, which is a reliable sign of peritoneal
inflammation (this accompanies appendicitis).
 Cough tenderness that is localized to a specific spot also signals peritoneal inflammation –
refer pt. with suspected appendicitis for CT.
 Suspect appendicitis:
 Obturator Sign: Lie supine lift their right leg up at 90 degree angle and you will hold at their ankle
and rotate it internally and externally. Abnormal response is pain.
 Iliopsoas Sign: Have patient on left side and move leg back. When the iliopsoas muscle is inflamed
(which occurs with an inflamed or perforated appendix), pain in felt in the RLQ.
 Shifting dullness?
 Ascites
 Lay them flat then shift them to their side and you will feel fluid upon percussion
 Signs for liver disease:
 Jaunidce eyes
 ictericsclera
 Bilirubinuria
Other Pathologies
 Umbilical hernia, do sit-up to see if it is a hernia.
Diastasis recti
Gastroschisis, born with intestine out.
Volvulus, really bad tangle
Intussusception, two intestines telescope into each other.
Important to know Different Signs. Different changes that occur with PEDS and ADULTS
Eyes – 7
 Parallel axes (conjugate movement) are important because the human brain can only one image.
 The muscle fibers of the iris contract the pupil in bright light and to accommodate for near vision;
they dilate the pupil in dim light and accommodate for far vision.
Subjective Data
 C/C: acuity changes? Blurring? Clouding (cataract)? Floaters? Blind spots? Night blindness? Halos?
 PHx
 Vision difficulty?
 Floaters are common with myopia or after middle age due to condensed vitreous fibers.
Usually not significant, but acute onset of floaters (shade or cobwebs) occurs with retinal
detachment. Happens in HTN, diabetic retinopathy, and dirty contacts.
 Halos around lights occur with acute narrow-angle glaucoma.
 Scotoma: a blind spots surrounded by an area of normal or decreased vision, occurs with
glaucoma, optic nerve disorders, and migraines.
 Night blindness occurs with optic atrophy (decreased visual field), glaucoma, or vitamin A
 Pain?
 Some common eye diseases cause no pain (i.e. cataract, glaucoma)
 Photophobia: the inability to tolerate light.
 Sudden onset of eye symptoms (pain, floaters, blind spot, loss of peripheral vision) is an
 Strabismus? Diplopia?
 Strabismus: deviation in the axis of the eye; unequal placement of the eyes
 Esotropia: inward deviation
 Exotropia: outward deviation
 Diplopia: the perception of two images of a single object
 Redness? Swelling?
 Watering? Discharge – color, amount, crusting/matting?
 Lacrimation and epiphora (excessive tearing) are due to irritants or obstruction in drainage
of tears. Xerophtalmia = dry eyes
 Purulent discharge is thick and yellow. Crusts form at night. Assess hygiene practices and
knowledge of cross contamination.
 Past history of ocular problems (i.e. allergies) and surgeries
 Allergens cause irritation of conjunctiva or cornea (i.e. makeup, contact lens solution)
 Surgery (i.e. Lasix, radiocaratonomy, lens replacements)
 Glaucoma: increased intraocular pressure
 Use of glasses or contact lenses
 With the use of corrective lenses, does your vision change?
 Contacts are a FB; take them out regularly.
 Self-care behaviors
 Last vision test
 Environment condition: work-related eye disease (i.e. an auto mechanic with a FB from
metal working or radiation damage from welding).
 Medications?
 Some medications affect the eyes (i.e. prednisone may cause cataracts or increased
intraocular pressure; beta blockers are used for ocular migraines and also used for HTN).
 Additional history for peds
 Any vaginal infections in the mother at time of delivery?
 Genital herpes and gonorrhea vaginitis have ocular sequelae for the newborn.
Objective – Physical Exam
 Far vision
 Snellen chart: E or picture chart
 3 - 6 years old: 20/30
 By 7- 6 years old: 20/20
 Remove only reading glasses because they will blur distance vision.
 Note hesitancy, squinting, leaning forward, and misreading letters.
The larger the denominator, the poorer the vision. If vision is poorer than 20/30, refer to an
ophthalmologist or optometrist. Impaired vision may be due to refractive error, opacity in
the media (cornea, lens, vitreous), or disorder in the retina or optic pathway.
 Picture cards (Allen Test)
 2-5 years old
 15 ft
 3/7 = normal
 “How many fingers am I holding up?”
 Use if lower than the largest letter/picture
Refer kids if….
 < 20/50 age 3 either eye
 < 20/40 age 4 either eye
 > 1 line difference between eyes
 Screen x 2 before referral
Near vision
 Hand held vision screener @ 14” from eyes
 14/14 in each eye, read without hesitancy and without moving the card closer or farther away is
a normal result.
 Presbyopia starts at age 40 (occurs in 50% of people) due the decrease in power of
accommodation with aging; takes you longer to focus (loss accommodation for near vision);
suggested when the person moves the card farther away.
Confrontation test – checks fields of vision
 Gross measure of peripheral vision
 If the person is unable to see the object as the examiner does, the test suggest peripheral field
loss. In an older adult, this screens for glaucoma. Acutely diminished visual fields occur with
diseases of the retina and stroke.
Color Blindness Assessment
 Ishihara’s test
 Primary colors: Red, Yellow, Green, Blue
 Male predominance: X-Linked Recessive Trait
Corneal Light Reflex (Hirschberg Test): Checks for strabismus or eso/exotropia
 Shine a light toward person’s eyes, note the reflection of light on the corneas; it should be in the
exact same spot on each eye.
 Asymmetry of the light reflex indicates deviation in alignment from eye muscle weakness or
paralysis. If you see this – perform cover test.
Cover test: checks for strabismus or eso/exotropia
 Detects small degrees of deviated alignment by interrupting the fusion reflex that normally
keeps the two eyes parallel – cover an eye and stare at an object
 Normal response is uncovered eyeball has a steady fixed gaze
 If one eye jumps to fixate on the designated point, it was out of alignment before.
 If muscles aren't mature/strong, covered eye would "wander"
 A phoria is a mild weakness noted only when fusion is blocked. Tropia is more severe – a
constant malalignment of the eyes.
Diagnostic positions test: checks neuromuscular function
 Lead the eyes through the 6 cardinal positions of gaze and it will elicit any muscle weakness
during movement.
 H pattern: up and down, left and right
 Left and right checks for nystagmus (eyes twitch when you look at extremes and also while
moving horizontally)
 Then 45° angle
 Normal response is parallel tracking of the object with both eyes.
 If eye movement is not parallel  Failure to follow in a certain direction indicates weakness
of extraocular muscle or dysfunction of cranial nerve innervating it.
 Note any nystagmus a fine oscillating movement seen around the iris.
 Mild nystagmus at an extreme lateral gaze is normal; any other position is note.
 Occurs with disease of the semicircular canals in the ears, a paretic eye muscle, multiple
sclerosis, or brain lesions.
 You should not see a white rim of sclera between the lid and the iris.
 Lid lag – occurs with hyperthyroidism.
 Brows
 Unequal or absent movement with nerve damage.
 Scaling occurs with seborrhea.
 Lashes/eyelids
 Incomplete closure creates risk for corneal damage.
 Palpebral fissures (opening b/w lids) are horizontal in non-Asians, whereas Asians normally
have an upward slant.
 Ptosis: drooping of upper lid
 Eyeballs
 African Americans normally may have a slight protrusion of the eyeball beyond the
supraorbital ridge.
 Exophthalmos: protruding eyes
 Enopthalmos: sunken eyes
 Conjunctiva (mucous membranes) and sclera: (white part)
 General reddening occurs in vascular disorders
 Cyanosis of the lower lids is abnormal
 Pallor near the outer canthus of the lower lids may indicate anemia (the inner canthus
normally contains less pigment).
 African Americans occasionally have a gray-blue or “muddy” color to the sclera. In darkskinned people, you may see small brown macules (like freckles) on the sclera – this is
normal. AA’s may have yellowish fatty deposits beneath the lids away from the cornea
(don’t confuse this with jaundice).
 Scleral icterus: an even yellowing of the sclera extending up to the cornea, indicating
 Note: tenderness, FB, discharge, or lesions.
 Lacrimal ducts
 Excessive tearing may indicate blockage of the nasolacrimal duct.
 Watch for any regurgitation of fluid out of the puncta, which confirms duct blockage.
 Note: puncta red, swollen, and tender to pressure
 Cornea/lens
 There should be no cloudiness
 A corneal abrasion causes irregular ridges in reflected light, producing a shattered look to
light rays.
 Iris/pupil
 Size (3-5 mm); decreases in response to light
 Anisocoria: having pupils of two different sizes
 May be normal or could indicate CNS injury
 Note any irregular shape – normally they’re round.
 Reflexes
 Consensual light reflex: if a stimulus is presented to one pupil (i.e. a bright light) and it
causes the pupil to constrict and dilate – the other pupil will have the same reflex
 Pupillary light reflex: normal constriction of the pupils when bright light shines on the retina.
 Subcortical reflex arc  the person has no conscious control over it
 Abnormal findings: dilated pupils, dilated & fixed pupils, unequal or no response to light,
 Direct light reflex: occurs when one eye is exposed to bright light, the pupil constricts
 Fixation: reflex direction of the eye toward and object attracting a person’s attention. The
image is fixed in the center of the visual field (fovea centralis). It consists of very rapid ocular
movements to put the target back on the fovea and somewhat slower movements track the
target and keep its image on the fovea.
 These movements are impaired by drugs, alcohol, fatigue, and inattention.
 Accommodation: adaption of the eye for near vision – observed by convergence of the
eyeballs and pupillary constriction.
 Absence of constriction, convergence, or asymmetric response is abnormal.
 Red Reflex: reflects off retina  'Red eye' in pictures
 Pupils
 Equal
 Round
 Reactive to Light
 Accommodation
 Fundoscopic Exam
 How to:
 Right Hand (hand holding opthalmoscope)
 Your right eye (where you should hold opthalmoscope) toview
 Their right eye
 Left hand on brow
 What you're looking for
 Optic disk: round, distinct, cream-orange, nasal side
 Arteries:Veins width should be 2:3 or 4:5
 Macula (straight back, dark color): want 2DD (2 disk diameter) temporal to disk
 Papilledema - inc. ICP
Cotton wool spots - diabetic retinopathy
Retinal Hemorrhage
Developmental Considerations
 Infants and children
Birth – 2 weeks: blink to bright light
2 – 4 weeks: fixate on objects
1 month: track light or bright objects
3 – 4 months: fixate, track, and reach for objects
Establishes binocularity and can fixate on a single image with both
eyes simultaneously.
6 – 10 months: track in all directions
 Peripheral vision is intact in newborn; macular is absent (develops by 4 months and matures by
 80% of neonates are born farsighted; this gradually decreases by 7 – 8 years old.
 Eyeball reaches adult size by age 8
 Aging adults
 Consistency changes from that of a soft plastic to rigid glass (d/t loss of elasticity).
 Lacrimal glands involute, causing decreased tear production and a feeling of dryness and
 Pupil size decreases
 By age 70 – the normally transparent fibers of the lens begin to thicken and yellow  senile
 Floaters appear d/t debris that accumulates because the vitreous is not renewed as
continuously as the aqueous humor.
 Common causes of decreased visual functioning:
 Cataract formation (lens opacity resulting for a clumping of proteins in the lens)
 Glaucoma (increased intraocular pressure)
 Affects men at higher rates than women
 Most common type: chronic open-angle glaucoma; gradual loss of peripheral vision
 Primary open-angle glaucoma affects blacks 3-6 times more than whites, and is 6 times
more likely to cause blindness in blacks than in whites.
 Macular degeneration (loss of central vision, the area of clearest vision)
 Most common cause of blindness
 Women more affected than men
 Peripheral vision is not affected
 Blindness
 In whites (older than 40) – leading cause is age-related macular degeneration, followed by
 In blacks–cataracts and open-angle glaucoma.
 In Hispanics – open-angle glaucoma
Common Abnormalities Eyes:
Pseduostrabismus: Eye aren't equal but it's okay
Epicathal fold excess on Asians, disappears with age
Bush field spot: white around pupil, common in children with down’s syndrome
Retinoblastoma! Seeing white in flash in a camera: light is not bouncing back = could mean cancer!
Increased pressure in the anterior chamber
Tonometry pressure testing
Red Eye
Conjuctivitis d/t varicella
Subjuctival hemorrhage: most likely caused by trauma
Hyphema: blood in anterior chamber of eye – trauma
Pseudostrabismus-epicanthal fold excess; more common in Asians; others disappear with age.
Brush field spot; NI variant? Common in Down syndrome
White spot in picture of eye means cancer for ALL ages. We always want a red reflux. Retinal
Blood in anterior chamber of eye- hyphema; can come from straining, getting hit.
Ectropion-bottom eyelid drops down
Entropion-bottom eyelid curls up.
Xanthelasma-cholesterol in the eyelid
Chalazion- cyst in the eyelid
Hordeoulum- stye- infection in hair follicle of eyelid
Basal cell carcinoma
Exophthalmus- bulging eyes
Coloboma- misshapen iris; dilated pupil
Aniscoria-uneven pupils; head trauma, stroke, etc
Pinguecula-growth in sclera
Pterygium-growth into eye that can affect vision
Ptosis-drooping of the upper lid
Ears, Nose, Mouth, Throat (Chapter 15 & 16) – 16
 Case: Bobby
 4 y.o. Bobby is brought into the clinic for c/o right ear pain for 2 days
 cc: OD pain x 2 d
 R otalgia x 2 day
 A &P
 Eustachian tube
 In children, it is more straight and short, so they have increased ear infections
 Babies should not lay flat while bottle feeding because they have eustachian tube
dysfunction. The effects of gravity and sucking draw the nasopharyngeal contents directly
into the middle ear.
 Labyrinth
 Vertigo: inflammation of labyrinth – creating a staggering gait and a strong, spinning,
whirling sensation.
Focused PHx/ROS
 Infections? (i.e. OM: otitis media, OE: Otitis externa)
 OM: obstruction of the eustachain tube or passage of the nasopharyngeal secretions into the
middle ear.
 90% of children younger than 2 years have had at least 1 case
 Predisposing factors: absence of breast feeding in the first 3 months, exposure to tobacco
smoke (passive or gestational), daycare attendance, male gender, pacifier use, seasonability,
and underlying diseases.
Side effect: middle ear effusion can impair hearing, placing a child at risk for delayed
cognitive development.
Discharge? (otorrhea – suggests infected canal or perforated ear drum)
 External otitis: purulent, sanguineous, or watery discharge
 Acute otitis media with perforation: purulent discharge
 Typically with perforation – ear pain occurs first, stops with a popping sensation, then
drainage occurs.
 Cholesteatoma: dirty yellow/gray discharge, foul odor.
 Otalgia may be directly due to ear disease or may be referred pain from a problem in teeth or
 Virus/bacteria from URI may migrate up the Eustachian tube to involve middle ear.
 Trauma may rupture TM.
Hearing loss?
 Adaptive devices?
 Children at risk for hearing deficit include those exposed to maternal rubella or to maternal
ototoxic drugs in utero; premature infants; low-birth weight infants; trauma or hypoxia at birth;
and infants with congenital liver or kidney disease.
Vertigo – true rotational spinning r/t dysfunction of labyrinth
 Objective: feels like room spins; subjective: person feels like he/she spins.
 Make sure to distinguish vertigo from dizziness or light-headedness
Ear Tubes or other surgery?
Tinnitus: ringing
(Meniere’s, ototoxic meds—Lasix, trauma)?
 Clearing with q-tips impact cerumen, causing hearing loss
Environmental noise?
 External Inspection
 Alignment, Size, Shape, Symmetry
 Microtia: ears smaller than 4 cm vertically
 Macrotia: ears larger than 10 cm
 Edema occurs with infection or trauma
 Skin:
 Note any eczema, seborrhea, SCC (squamous cell carcinoma), decubiti (ulcer), sebaceous
crust, chondrodermatitis, tophi
 Reddened, excessively warm skin indicates inflammation.
 Crusts and scaling occur with otitis externa and with eczema, contact dermatitis, and
 Enlarged tender lymph nodes in the region indicate inflammation of the pinna or mastoid
 Masses, nodes, nodules, furuncles--cyst under the skin
Darwin’s tubercle: small painless nodule at the helix; congenital variation and not
 Tenderness @ pinna and tragus
 Pain with movement occurs with otitis externa and furuncle.
 Pain at the mastoid process may indicate mastoiditis or lymphadenitis of the posterior
auricular node.
 Mastoiditis can cause hearing loss.
 External Auditory Meatus: should be clear of swelling, redness, and discharge
 Drainage (otorrhea) is abnormal
 A sticky yellow discharge accompanies otitis externa, or it may indicate otitis media if the
drum has ruptured
 Hygiene
Otoscopic Examination
 Developmental considerations
 Child (less than three years): pull pinna down and back
 Adult: (because taller) up and back to help straighten the S-shape of the canal
 External canal – note color, lesions, masses and discharge
 Redness and swelling occur with otitis externa, the canal may be completely closed with
 Purulent otorrhea suggests otitis externa or otitis media if the drum has ruptured.
 Frank blood or clear watery drainage (cerebrospinal fluid leak) after trauma suggests basal skull
fracture and warrants immediate referral. Cerebrospinal fluid feels oily and tests positive for
 Abnormal findings: FB, exostosis, polyp, furuncle
 Tympanic Membrane
 Color and Characteristics
 Yellow-amber color of the drum occurs with serous otitis media
 Red color occurs with acute otitis media
 Note absent or distorted landmarks
 Landmark: umbo
 Air/fluid level or air bubbles behind the drug indicate serous otitis media
 Position
 Normal: flat, slightly pulled at center, and flutters when the person performs the Valsavla
maneuver (avoid in older person  disrupts equilibrium), or insufflation (avoid in pt with
URI  proper infectious matter into middle ear)
 Abnormal
 Retracted drum due to vacuum in middle ear
 Bulging drum from increased pressure; no cone of light; cannot see umbo
 Eardrum does not move
 Integrity of Membrane – intact
 Perforation shows as a dark oval or as a larger opening on the drum.
 White patch may indicate scarring
Insufflator: attaches to otoscope to push a little air and makes tympanic membrane move
 Words to know
 Malleus (manubrium of)
 Umbo (tip of manubrium of malleus)
 Reflected cone of light (looking for it when shining light in your ear)
 Right ear: cone of light is at 5 o clock
 Left ear: cone of light is at 7 o clock
 Audiometry
 Whisper (voice)
 Passing: 3/6 numbers/letters
 Abnormal: person is unable to hear whispered items. A whisper is a high-frequency sound
and is used to detect high-tone loss.
 Watch: hearing the click of a watch
 Tuning Fork
 Weber: tuning fork on top of head
 Sound lateralizes to >
 Good ear: sensorineural (CN VIII ) loss
 Bad ear: conductive loss
 Rinne: tuning fork on mastoid bone, will time it. When patient does not hear anymore,
move it to their ear.
 AC [Air conduction] 2x > BC [Bone conduction] = nl; Ratio 2:1***
 ex/ 30 seconds to feel, 60 seconds to hear
 If bone conduction is greater, you have a conductive hearing loss
 BC > AC = Conductive loss
 AC > BC but overall reduced = Sensorineural loss
 If Weber test lateralizes to one side, do Rinne to confirm
 Startle
 Conductive
 Mechanical obstruction: cerumen, FB, rupture, OM/E, ETD--Eustachian Tube D...
 Acoustic neuroma--brain tumor that grows in the inner ear
 Tympanometry: presence of fluid in the middle ear, mobility of the middle ear system, and ear
canal volume
Developmental Considerations
 Infants and Children
 Maternal rubella infection occurs during the first trimester  damage of the organ of Corti and
impair hearing.
 Eustachian tube is relatively short and wider and more horizontal  easier for pathogens from
the nasopharynx to migrate to the middle ear  increases risk for ear infections
 Low set ears are found with trisomy 13, 15, 21. Large, prominent ears, misshapen ears, and
creases on earlobes are nonspecific but occur with certain syndromes and with underlying ear
structure abnormalities. Pre-auricular skin tags may occur alone or with other facial anomalies.
 Use a pneumatic bulb to assess the vibratility – normally membrane moves inward with puff of
air and outward with a slight release.
An abnormal response is no movement of the eardrum. Drum hypomobility indicates
effusion or a high vacuum in the middle ear. For the newborn’s first 6 week, drum
immobility is the best indicator of middle ear infection.
 Look for FBs  increased risk for trauma
 The incidence of meningitis, measles, mumps, OM, and any illness with persistent high fever
may increase risk for hearing deficit.
 The adult
 Otosclerosis: common cause of conductive healing loss in young adults b/w the ages of 20 and
40; gradual hardening  fixation of stapes in oval window  impeding transmission of sound
 progressive deafness
 Aging adult
 Accumulation of cerumen d/t coarse/stiff cilia  reduces hearing
 Impacted cerumen (occurs in 57% of older adults) is associated with hearing loss.
 Blocks conduction from hearing aids
 Presbycusis: gradual sensorineural loss causes by nerve degeneration in the inner ear that slowly
progresses after the 5th decade; accentuated when unfavorable background noise is present (i.e.
music, dishes clattering, or at a noisy party).
Abnormal Findings
External Ear
 Frostbite: reddish blue discoloration and swelling of auricle after exposure to extreme cold. Vesicles or bullae
may develop, the person feels pain and tenderness, and ear necrosis may ensue.
 OE (swimmer’s ear): infection of outer ear, with severe painful movement of the pinna and tragus, redness
and swelling of pinna and canal, scanty purulent discharge, scaling, itching, fever, and enlarged tender regional
lymph nodes. Hearing is normal or slightly diminished. More common in hot, humid weather. Swimming
causes canal to become waterlogged and well; skinfolds are set up for infection. Prevent by using rubbing
alcohol or 2% acetic acid eardrops after every swim.
 Branchial Remnant and Ear Deformity: a facial remnant or leftover of the embryologic branchial arch usually
appears as a skin tag. Occurs most often in the preauricular area, in front of the tragus. When bilateral, there
is increased risk for renal anomalies.
 Cellulitis: inflammation of loose, subcutaneous connective tissue. Shows as thickening and induration of
auricle with distorted contours.
Lumps and Lesions
 Sebaceous cyst: Common location is behind lobule, in the postauricular fold. A nodule with central black
punctum indicated blocked sebaceous gland. It is filled with waxy sebaceous material and is painful if infected.
 Tophi: small, whitish yellow, hard, nontender nodules in or near helix or antihelix; contain greasy, chalky
material of uric acid crystals and are a sign of gout.
 Chondrodermatitis Nodularis Helicus: painful nodules develop on the rim of the helix (where this is no
cushioning subcutaneous tissue) as a result of repetitive mechanical pressure or environmental trauma
(sunlight). They are small, indurated, dull red, poorly defined, and very painful
 Keloid: overgrowth of scar tissue, which invades original site of trauma. It is more common in dark-skinned
people, although it also occurs in whites. In the ear it is most common at lobule at the site of a pierced ear.
 Carcinoma: ulcerated, crusted nodule with indurated base that fails to heal. Bleeds intermittently. Must refer
for biopsy. Usually occurs on the superior rim of the pinna, which has the most sun exposure. May occur also
in ear canal and show chronic discharge that is either serosanguineous or bloody.
Ear Canal
 Excessive cerumen: produced or impacted because of narrow, tortuous canal or poor cleaning method. Even
when canal is 90-95% blocked, hearing stays normal; when cerumen expands after swimming or showering,
person has ear fullness and sudden hearing loss.
 OE: severe swelling of canal, inflammation, tenderness.
 FB
 Osteoma: single, stony hard, rounded nodule that obscures the drum; nontender; overlying skin appears
normal. Attached to inner third, the body part, of canal. Benign, but refer for removal.
 Exostosis: more common than osteoma. Small, bony hard, rounded nodules of hypertrophic bone, covered
with normal epithelium. They arise near the drum, but usually do not obstruct the view of the drum. They are
usually multiple and bilateral. They may occur more frequently in cold-water swimmers. The condition needs
no treatment, although it may cause accumulation of cerumen, which blocks the canal.
 Polyp: arises in canal from granulomatous or mucosal tissue; redder than surrounding skin and bleeds easily;
bathed in foul, purulent discharge; indicates chronic ear disease. Benign, but refer for excision.
 Furuncle: exquisitely painful, reddened, infected hair follicle. It may occur on the tragus on the cartilaginous
part of ear canal. Regional lymphadenopathy often accompanies a furuncle.
Tympanic Membrane (page 346)
 Discharge
 Altered smell – anosmia
 Sense of smell diminishes with cigarette smoking, chronic allergies, aging
 Smoking
 Frequent colds (upper respiratory infections)
 Allergies or sinus pain
 “seasonal” rhinitis if due to pollen; “perennial” if allergen is dust
 Misuse of OTCs irritate the mucosa and cause rebound swelling.
 Epistaxis (nose bleeds) – occurs with trauma, vigorous nose blowing, FB
 Trauma – can cause deviated septum, which may cause nares to be obstructed
 Inspection
 Lesions (BCC--basal cell carcinoma; more deadly than SCC although doesn't look worse, SCC)
impetigo, deformities, discharge, asymmetry, and inflammation
 Absence of sniff indicates obstruction (i.e. nasal polyps, rhinitis)
 Nasal speculum: look for deviation, perforation, or bleeding
 Deviated septum looks like a hump or shelf in one nasal cavity.
 Perforation is seen as a spot of light from penlight shining in the other naris.
 Epitaxis commonly comes from the anterior septum; Kiesselbach plexus is the most
common site.
 Turbinates: note any swelling, tender to touch, vascular
 Polyps (benign growths that accompany chronic allergy) are smooth, pale gray, avascular,
mobile, and nontender.
 Nasal cavity: normal red color, smooth moist surface
 Note any swelling, discharge, bleeding, FB
 Rhinits: nasal mucosa is swollen and bright red with an upper respiratory infection
Discharge is common with rhinitis and sinusitis, varying from watery and copious to thick,
purulent, and green-yellow.
 With chronic allergy, mucosa looks swollen, boggy, pale, and gray.
 Palpation
 Sinuses
 Sinus areas are tender to palpation in persons with chronic allergies and acute infection
 Rhinitis
 Acute vs. Allergic
 Acute: Purulent, Red turbinates, Unilateral (possibly d/t FB), Allergic, Clear, Pale boggy, Itchy,
watery eyes, lines above their nose r/t always wiping
 Sinusitis
 Polyps (gray)
 Epistaxis (nosebleeds)
 Caused by trauma, vigorous nose blowing, foreign body
Mouth & Throat
 Sores or lesions?
 Sore throat?
 Untreated strep throat may lead to the complication of rheumatic fever
 Bleeding gums?
 Dental problems? Toothache?
 Dentures? Correct fit?
 Vocal hoarseness (dysphonia)?
 R/T overuse of voice, URI, chronic inflammation, lesions, or a neoplasm
 Dysphagia?
 Occurs with pharyngitis, GERD, stroke & other neurological disorders, and esophageal
 Taste alterations?
 Self-care behaviors
 Dental care/check-ups? (should be every six months for cleaning as you get older)
 Dental appliances (braces, dentures, bridges)?
 Lesions may arise form ill-fitting dentures, or the presence of dentures may make the
eruption of new lesions.
 Chronic tobacco use leads to tooth loss, coronal and root caries, and periodontal disease in
older adults.
 Increase risk for oral and pharyngeal cancers
 Inspection:
 Lips: Color, moisture, texture, vermilion border (border all the way around the lips)
 Abnormals:
 Angular cheilitis (perleche) (cracking on the side of the mouth)
 HSV I--herpes simplex virus 1 (typically oral; 2 is not oral but can be there
 Cyanosis (hypoxemia and chilling), cherry red lips/nose/cheecks (CO poisoning- late
sign), acidosis (aspirin poisoning or ketoacidosis)
 Gums: Color, swelling, atrophy, bleeding
 Dark lines gums = lead poisoning
 Teeth: Color, spacing, hygiene, occlusion
 Discolored teeth appear brown with excessive fluoride use, yellow with tobacco use.
 Grinding down of tooth surface; plaque – soft debris; caries – decay.
 Malocclusion (poor biting relationship), protrusion of upper or lower incisors
 Gingivitis hyperplasia, crevices between teeth and gums, pockets of debris.
 Gums bleed with slight pressure indicates gingivitis.
 Dark line on gingival margins occurs with lead and bismuth poisoning.
 Tongue:
 Sublingual/frenulum: Color, Texture, Coatings
 Palpate salivary glands
 Beefy red, glossy (B12 deficiency)
 should be pink and even
 Furrows (= dehydration)
 Black hairy (meds)
 Tremors (could possibly be from hyperthyroid
 Enlarged tongue occurs with mental retardation, hypothyroidism, acromegaly; a small
tongue accompanies malnutrition.
 Dry mouth occurs with dehydration, fever; tongue has deep vertical fissures.
 Saliva is decreased when taking anti-cholinergic medications
 Excess saliva and drooling occur with gingivostomatitis and neurologic dysfunction
 A fine tremor of the tongue occurs with hyperthyroidism; a coarse tremor occurs with
cerebral palsy and alcoholism.
 Tonsils: Color (Exudate: whiteness), Crypts
 Size : large child & atrophy w/ age
 rating tonsils
 1+ visible
 2+ 50%
 3+ touches uvula
 4+ kissing each other (painful)
 Bifurcated uvula – more common in American Indians
 Deviation to the side or absent movement indicates nerve damage, which also occurs with
poliomyelitis and diphtheria.
 Bucca mucosa – pink, smooth, moist
 Dappled brown patches are present with Addison’s disease
 Orifice of Stensen’s duct looks red with mumps
 Koplik spots are an early warning sign of measles.
 Palate (hard and soft palate)
 Soft
 “Ahhh…” CN IX & X
 Uvula should go up
 Hard
 Appears yellow with jaundice (in blacks with jaundice – it may appear yellow, muddy yellow,
or green-brown).
 Oral Kaposi sarcoma is the most common early lesion in people with AIDS
 Torus palatinus: benign growth arises after puberty and is a more common finding in
American Indians, Inuits, and Asians.
 A high-arched palate is usually normal in the newborn, but very narrow or high arch also occurs
with Turner’s syndrome, Ehlers-Danlos syndrome, Marfan’s syndrome, and Treacher Collins
syndrome or develops in the mouth-breather in chronic allergies.
Angioedema: swelling of mouth and eyes
Leukoplakia: side of whiteness, normal
Geographic tongue: nothing wrong
Glossitis: bright, red, can be enlarged, glossy
Thrush: tongue is red and inflamed, white patches (can get it from fungal infection, which you can
get from antibiotics)
Black hairy tongue r/t antibiotics
Ankyloglossia: short tongue syndrome - frenulum is too short, may have difficulty with bottle
feeding; can limit protrusion and impair speech development
Strep vs. Mono
 Petechiae soft palate  strep
Aphthous ulcers: ulcers inside mouth
Sialolith (stones)
 Halitosis: bad breath; can be caused by sinus, caries, strep
 Ketosis: sweet smell, occurs in diabetic ketoacidosis
 Acetone breath smell occurs in children with malnutrition or dehydration.
 Ammonia breath occurs with uremia
 Musty odor with dental or respiratory infections
 Alcohol odor with alcohol ingestion or chemicals
 Mouse-like smell with diphtheria
S/S infection
 Red
 Pus
 Fever
 Dysphagia
 Child
 Obligate nose breathers
 Inability to suction out nose is bad, because they cannot breathe through mouth.
 Nasal flaring in the infant indicates respiratory distress
 Choanal atresia: inability to pass catheter through nasal cavity – requires immediate
 Natal teeth (baby teeth that develop in uterine) vs. Epstein’s pearls (white cysts on gum line)
 Discolored teeth appear yellow or yellow-brown with infants taking tetracycline or whose
mothers took the drug during the last trimester; appear green or black with excessive iron
ingestion, although this reverses when iron is stopped.
 Cleft palate / lip
 Teeth
 Begin 6 m-2 ½ yr.
 (age in mo's – 6 = approx. # teeth they should have)
 20 Deciduous lost by 6-12 yr. of age
 Baby Bottle tooth decay: consistent bottle drinkers are missing top front teeth, because of sugar
in milk and juice (this also increases risk for middle ear infections)
 Tooth eruption is delayed with Down syndrome, cretinism, rickets.
 Prolonged thumb sucking (after age 6 or 7) may affect occlusion.
 Bruxism (teeth grinding) occurs in sleep from dental problems or nervous tension.
 Pregnancy
 Hyperplasia: swelling, increased blood flow/supply that goes everywhere (normal)
 Caries = myth
 Rhinitis
 Aging
 Decreased saliva production  dry mouth (xerostomia)
 Dry mouth also causes by side effect of many drugs (i.e. antidepressants)
 Decreased taste
 Possibly r/t medications
 People add extra salt and sugar to food.
 Diminished smell may decrease the person’s ability to detect food spoilage, natural gas
leaks, or smoke from a fire.
 Osteoporosis
 SQ wasting  dental problems (i.e. dentures could not fit as well as possible)

Respiratory – 9 - Student Nurses Association: UCF Orlando Campus