Physical Assessment Review Study Guide Exam #1
1.
2.
3.
4.
5.
Know difference between subjective and objective data and examples of each
a.
Subjective: what the person says about him/herself during history taking
b. Objective: what the health professional observes by inspecting, palpating, percussing, and auscultating during the physical exam
Know sections of a complete database
a.
Complete database: includes a complete health history and a full physical examination (as well as pt record and laboratory studies); describes the
current and past health state and forms a baseline against which all future changes can be measured (yields the first diagnosis)
b. For the healthy person:
i. Describes the person’s health state, perception of health, strengths or assets such as health maintenance behaviors, individual coping
patterns, support systems, current developmental tasks, and any risk factors or lifestyle changes
c.
For the ill person:
i. Also includes a description of the person’s health problems, perception of illness, and response to the problems
d. Screening for pathology and determine the response to the pathology (or any health problems)
i. Used to refer pt to another professional, to help pt make decisions, and perform appropriate treatments
e.
Notes human response to health problems
f.
Collect pts perception of illness, functional ability or patterns of living, ADLs, health maintenance behaviors, response to health problems, coping
patterns, interaction patterns, and health goals
g. All used to make a nursing diagnosis
Know a persons culture: how does it develop and basic characteristics
a.
What are examples of first and second level priorities--difference between each level
a.
First-level priority: those that are emergent, life threatening, and immediate
i. Establishing airway or support breathing, circulation (ABCs)
b. Second-level priority: those that are next in urgency—requiring prompt interventions to forestall further deterioration
i. Mental status changes, acute pain, acute urinary elimination problems, untreated medical problems, abnormal lab values, risk of
infection, or risk to safety or security
What are the components of a health history and what types of data go in each section—examples
a.
Present health or history of present illness: Summary of symptoms
i. Location: specific; as person to point to the location
1. Ex: pain behind the eyes; jaw pain, occipital pain
ii. Character or quality: descriptive terms such as burning, sharp, dull, aching
1. Ex: “does the blood in the stool look like sticky tar?”
iii. Quantity or severity: quantify the symptom of pain using a scale; as how it affects their daily activities
1. Ex: “I was able to go to work, but them I came home and went to bed;” “I was so sick I was doubled up and couldn’t
move.”
iv. Timing: onset, duration, frequency
1. Include questions such as, How long did the symptoms last (duration), Was it steady (constant), Did it come and go
(intermittent), Did it resolve completely or reappear days or weeks later (cycle of remission and exacerbation)
v. Setting: where was the person, or what where they doing when symptoms started; what brought it on
1. Ex: “Did you notice the chest pain after shoveling snow, or did the pain start by itself?”
vi. Aggravating or relieving factors: What makes the pain worse; is it aggrevated by weather, activity, food, meds, standing bent over;
fatigue; time of day; season… what relieves it; what are the effects of treatment
1. Ex: “what have you tried,” or “what seems to help”
vii. Associated factors: is the primary symptom associated with any others? Is the symptom a side effect of a med or lifestyle factor
(smoking)
1. Ex: urinary frequency and burning associated with fever and chills
viii. Patient’s perception: find out the meaning of the symptom by asking how it affects daily activities
b.
Past history
i. Childhood illnesses (MMR, chickenpox, pertussis, strep throat)
1. Avoid recording usual childhood illnesses
ii. Accidents or injuries
iii. Serious or chronic illnesses
iv. Hospitalizations
v. Operations
vi. Obstetric history
vii. Immunizations
viii. Last exam date
ix. Current meds
x. Allergies and reaction
c.
Family history
i. Genogram
d. Review of systems
i. Purpose:
1. Evaluate the past and present health state of each body system
2. Double check in case any significant data were omitted in the Present Illness section
3. To evaluate health promotion practices
ii. General overall health state, skin, hair, head, eyes, ears, nose and sinuses, mouth and throat, neck, breast, axilla, respiratory, CV, PV,
GI, GU, sexual health, musculoskeletal, neuro, hematologic, endocrine
e.
Functional assessment (including ADLs)
i. Measures a person’s self-care ability in the areas of general physical health or absence of illness
ii. IADLs (instrumental ADLs): bathing, dressing, toileting, eating, walking
iii. Those needed for independent living: housekeeping, shopping, cooking, laundry, telephone, finances, nutrition, relationships
iv. Sections:
1
1.
6.
7.
8.
Self-esteem, self-concept
a.
Education, financial status, value belief system
2. Activity/Exercise
a.
Ask how they spend their typical day; ADLs and need for assistance; leisure activities; exercise patterns
(amount, type, frequency)
3. Sleep/rest
a.
Patterns; naps; sleep aids
4. Nutrition/elimination
a.
24hr recall and ask if it is typical; who buys food/prepared food; who is present during meal times; food
allergies; daily intake of caffeine; bowel and urinary problems/frequency/habits
5. Interpersonal relationships/resources
a.
Family role; how do they get along with family/friends/co-workers; support systems
6. Spiritual resources
a.
Does religion play a role in their life, does it influence how they view health, are they part of a religious group
7. Coping and stress management
8. Personal habits
9. Alcohol use/drug use
10. Environment/hazards (living situation)
11. Intimate partner violence
12. Occupational health
f.
Perception of health
i. Definition of health
Discuss the interview process--what needs to be considered
a.
What are the four physical assessment techniques--usual order, purpose of each, what is done in each section (exception to this order is the
abdomen)
a.
Inspection:
i. Initial “general survey” then inspect each body system without touching
ii. Look for symmetry
iii. Must have good lighting, adequate exposure, and occasional use of instruments (otoscope, ophthalmoscope, light, specula)
b. Palpation:
i. Follows and confirms points noted during inspection
ii. Use of touch to assess texture, temp, moisture, organ location and size, swelling, vibration or pulsation, rigidity or spasticity,
crepitation, presence of lumps or masses, and presence of tenderness or pain
iii. Parts of hands used:
1. Fingertips: best for fine tactile discrimination (skin texture, swelling, pulsation, lumps)
2. Grasping with finger and thumb: detect position, shape, and consistence of an organ or mass
3. Dorsa (back of hand): determining temp
4. Base of fingers: vibrations
iv. Slow and systematic; avoid sudden movements that will make the pt tense up
v. Palpate tender areas last
vi. Light palpation: done first to detect surface characteristics
vii. Deep palpations: use intermittent pressure for abdominal contents
c.
Percussion:
i. Tapping the skin with short, sharp strokes to assess underlying structures
1. Mapping out location and size of an organ (exploring where the percussion note changes between borders of organs)
2. Density (air, fluid, or solid) of structures
3. Detecting abnormal masses that are fairly superficial (percussion only penetrated ~5cm (deeper masses would give no
change in percussion)
4. Eliciting pain if structures are inflamed
5. Eliciting deep tendon reflexes with percussion hammer
ii. Plexor strikes the pleximeter
iii. Notes:
1. Resonant: clear, hollow; over normal lung tissue
2. Hyperresonant: Booming; normal over child’s lungs; abnormal in adults (hyperinflated lungs such as emphysema and
COPD)
3. Typany: musical and drum-like; over air-filled viscus (stomach and intestine)
4. Dull: muffled thud; relatively dense organs (liver and spleen)
5. Flat: dead stop of sound, absolute dullness; no air is present, over thigh muscle, bone, or over a tumor
d. Auscultation:
i. Stethoscope:
1. Diaphragm: high-pitched sounds (breath, bowel, and normal heart sounds)
2. Bell: low-pitched sounds (extra heart sounds, murmurs, BP)
Discuss levels of hypertension
a.
Normal:
i. <120/<80
b. Prehypertension:
i. 120-139/80-89
ii. No drugs indicated
c.
Hypertension (Stage 1):
i. 140-159/90-99
ii. Thiazide diuretics for most; may consider ACE inhibitors, ARBs, BB, CCB, or combo
d. Hypertension (Stage 2):
i. >160/>100
2
ii. Two-drug combo for most; usually Thaizide and ACEI, or ARB, BB, CCB
Errors in readings
i. Falsly high:
1. Anxiety or anger
2. Arm below level of heart
3. Person supports arm (high diastolic)
4. Legs crossed
5. Inaccurate cuff size (cuff too narrow)
6. Deflating cuff too slowly (high diastolic)
7. Repeating BP reading before 1-2min rest (high diastolic)
8. Deflating cuff too quickly (high diastolic)
ii. Falsely low:
1. Arm above heart level
2. Not inflating cuff above systolic BP (low systolic)
3. Pushing stethoscope to hard (low diastolic)
4. Deflating cuff too quickly (low systolic)
Four areas of the general survey:
a.
Physical appearance
b. Body structure
c.
Mobility
d. Behavior
e.
Measurements
i. BMI kg/m2
1. Underweight <18.5
2. Normal weight 18.5-24.9
3. Overweight 25-29.9
4. Obesity (class 1) 30-34.9
5. Obesity (class 2) 35-39.9
6. Extreme obesity (class 3) >40
ii. Waist circumference
1. Men >40in or women >35in at risk for DM type 2, dyslipidemia, HTN, and CVD (with BMI b/t 25 and 35)
iii. Temp:
1. Wait 15min after beverages; 2min after smoking
2. Older adults usually lower temp—mean of 36.2˚C (97.2˚F)
3. Morning: 1-1.5˚F variation
4. Menstruation: 0.5-1.0˚F rise
iv. HR
1. Normal: 50-90bpm (conventional range is 60-100bpm)
v. RR:
1. Normal: 10-20 breaths/min
e.
9.
FOR EACH OF THE FOLLOWING SYSTEMS—REVIEW HEALTH HISORY QUESTIONS FOR EACH AND POSSIBLE NURSING DIAGNOSES
SKIN, PVS, and Lymphatic System (Ch. 12 & 20):
1.
Know anatomy and physiology
a.
Layers
i. Epidermis:
1. Thin, tough protective barrier; avascular
2. Inner basal layer: forms new skin cells, contains melanocytes: skin color, and new skin cells become keratinized.
Keratinized cells - dead cells
3. Outer horny cell layer: layer of dead cells that packed closely and sheds constantly. extra (5th layer) on palms and soles
4. Keratin (strength)
5. Pigment
a.
Melanocytes (brown)
b. Carotene (yellow-orange)
c.
Vascular beds (red-purple)
6. Replaced every 4 weeks (shed 1lb of skin/year)
ii. Dermis: supportive layer; mostly connective tissue (collagen); contains nerves, sensory receptors, BVs, and lymphatics; appendages
(hair follicles, sebaceous glands, and sweat glands)
iii. Subcutaneous: adipose tissue (fat for energy, insulation, and cushion)
iv. Function of skin
1. Identification/color: via melanin (brown), carotene (yellow-orange),
2. Vascular bed (red-purple)
3. General protection: microbes, physical, chemical, thermal, light
4. Prevents penetration: microbes entering
5. Sensory & perception: feel things like temp, tactile, pain
6. Temp regulator: sweat for too hot, fat for too cold
7. Communication: nonverbal, blushing
8. Wound repair: scar tissue
9. Absorption & secretion: ex. topical meds % secrete oil/sweat
10. Vit D production + absorption: converts cholesterol to Vit D, SUN
2. Know order of physical examination and order of what is done in each section AND HOW IT IS DONE
Inspect and Palpate the Skin:
3
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Color:
o
o
General pigmentation: observe skin tone; even and consistent with genetic background (freckles, moles)
Widespread color changes: note any color change over the entire body skin, such as pallor (white); erythema (red), cyanosis (blue), and jaundice
(yellow)
Temperature:
o
Note the temperature of your own hands
o
Use the backs of your hands to palpate the person and check bilaterally
o
Skin should be warm, and the temperature should be equal bilaterally; warmth suggests normal circulatory status; hands and feet may be slightly
cooler
o
Hypothermia: generalized coolness may be induced, such as in hypothermia used for surgery or high fever; localized coolness is expected with an
immobilized extremity
o
Hyperthermia: generalized hyperthermia occurs with an increased metabolic rate (fever)
Moisture:
o
Diaphoresis – profuse perspiration
o
Dehydration – oral mucous membranes; normally none
Texture:
o
Normal skin feels smooth and firm, with an even surface
Thickness
Edema (1+, 2+, 3+, 4+)
Mobility and Turgor
Vascularity or bruising
Lesions (color, elevation, pattern/shape, size [cm]; location, any exudate)
Inspect and Palpate the Hair:

Color
o
Hair color comes from melanin production and may vary from pale blonde to total black
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Texture
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Distribution
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Lesions
Inspect and Palpate the Nails:
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Shape and Contour (normally slightly curved or flat; the profile sign)
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Consistency
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Color
a.
Capillary refill
3. Describe types of primary and secondary lesions—size and shapes—(e.g. bullae, papule, nodule; elliptical, linear shape)
a.
Primary lesion: lesion that develops on previously unaltered skin
i. Macule:
1. Color change, flat and circumscribed
2. <1cm
3. Ex. Freckles, flat nevi, hypopigmentation, petehiae, measles, scarlet fever
ii. Patch:
1. Macules >1cm
2. Ex. Mongolian spots, vitiligo, café au lait spot, chloasma, measles rash
iii. Papule:
1. Solid, elevated, circumscribed lesion caused by superficial thickening in the epidermis
2. <1cm
3. Ex. Elevated nevus, lichen planus, molluscum, wart (verruca)
iv. Plaque:
1. Papules coalesce to form surface elevation; plaque-like, disk-shaped lesion
2. Wider than 1cm
3. Ex. Psoriasis, lichen planus
v. Nodule:
1. Solid, elevated, hard or soft; may extend deeper into dermis than papule
2. >1cm
3. Ex. Xanthoma, fibroma, intradermal nevi
vi. Wheal:
1. Superficial, raised, transient, and erythematous; slightly irregular shape due to edema
2. Ex. Mosquito bite, allergic reaction, dermographism
vii. Tumor:
1. Firm or soft, deeper into dermis; may be benign or malignant
2. >few cm
3. Ex. Lipoma, hemangioma
viii. Urticaria (Hives)
1. Wheals coalesce to form extensive reaction; intensely pruritic
ix. Vesicle:
1. Elevated cavity containing free fluid; blisters; clear serum flows if wall is ruptured
2. Up to 1cm
3. Ex. Herpes simplex, early varicella (chickenpox), herpes zoster (shingles), contact dermatitis
x. Bulla:
1. Usually single chambered (unilocular); superficial in epidermis; thin walled; ruptures easily
2. >1cm
3. Ex. Friction blisters, pemphigus, burns, contact dermatitis
4
xi.
4.
Cyst:
1. Encapsulated fluid-filled cavity in dermis or subq layer, tensely elevating skin
2. Ex. Sebaceous cyst, wen
xii. Pustule:
1. Turbid fluid (pus) in cavity; circumscribed and elevated
2. Ex. Impetigo, acne
b. Secondary lesion: lesion changes over time of changes because of a factor such as scratching or infection
i. Crust:
1. Thickened, dried-out exudate left when vesicle/pustules burst or dry up
2. Color red-brown, honey, or yellow depending on fluid ingredients (blood, serum, pus)
3. Ex. Impetigo (dry, honey-colored), weeping eczematous dermatitis, scab after abrasion
ii. Scale:
1. Compact, desiccated flakes of skin, dry or greasy, silvery or white, from shedding of dead excess keratin cells
2. Ex. After scarlet fever or drug reaction (laminated sheets), psoriasis (silver, mica-like), seborrheic dermatitis (yellow,
greasy), eczema, ichthyosis (large, adherent, laminated), dry skin
iii. Fissure:
1. Linear crack with abrupt edges, extends into dermis, dry or moist
2. Ex. Cheilosis—at corners of mouth due to excess moisture; athlete’s foot
iv. Erosion:
1. Scooped out but shallow depression; superficial; epidermis lost; moist but no bleeding; heals w/out scar b/c erosion does
not extend into dermis
v. Ulcer:
1. Deeper depression extending into dermis; irregular shape; may bleed; leaves scar when heals
2. Ex. Stasis ulcer, pressure sore, chancre
vi. Excoriation:
1. Self-inflicted abrasion; superficial; sometimes crusted; scratches from itching
2. Ex. Insect bite, scabies, dermatitis, varicella
vii. Scar:
1. After a skin lesion is repaired, normal tissue is lost and replaced with connective tissue (collagen); permanent fibrotic
change
2. Ex. Healed area of surgery or injury, acne
viii. Atrophic scar:
1. The resulting skin level is depressed with loss of tissue; a thinning of the epidermis
2. Ex. striae
ix. Lichenification:
1. Prolonged, intense scratching eventually thickens the skin and produces tightly packed sets of papules; looks like surface
moss (or lichen)
x. Keloid:
1. A hypertrophic scar; the resulting skin level is elevated by excess scar tissue, which is invasive beyond the site of original
injury; may increase long after healing occurs; looks smooth, rubbery, and claw-like and has a higher incidence among
Blacks
Know vascular lesions and markings (p. 238-240)
a.
Hemangiomas:
i. Port-wine stain (Nevus Flammeus):
1. Large, flat, macular patch covering scalp or face (freq. along distribution of CN V)
2. Color: red, bluish, or purplish and intensifies with crying, exertion, or exposure to heat/cold
3. Consists of macular capillaries
4. Present at birth; does not fade
5. Photoablation of lesion with yellow light lasers
ii. Strawberry mark (Immature Hemangioma):
1. Raised bright red area with well-defined borders (2-3cm diameter)
2. Non-blanchable w/ pressure
3. Consists of immature capillaries
4. Present at birth or develops within first few months (disappears by age 5 to 7)
5. Requires no Tx
iii. Cavernous hemangioma (Mature):
1. Reddish blue, irregularly shaped, solid and spongy mass of blood vessels
2. May be present at birth, enlargement in first 10-15 months, and will not involute spontaneously
b. Telangiectases:
i. Telangiectasia:
1. Caused by vascular dilation
2. Permanent enlargement and dilated BVs visible on skin surface
ii. Spider or Star Angioma:
1. Fiery red, star-shaped marking with a solid circular cener
2. Capillary radiations extend from central arterial body
3. With pressure, note a central pulsating body and blanching of extended legs
4. Develops on face, neck, or chest
5. May be associate w/ preg, chronic liver disease, or estrogen therapy, or may be normal
iii. Venous Lake:
1. Blue-purple dilation of venules and capillaries in a star-shaped, linear, or flaring pattern
2. Pressure causes them to empty or disappear
3. Located on legs near varicose veins; also on face, lips, ears, and chest
c.
Purpuric Lesions:
5
i.
5.
6.
7.
Petechiae:
1. Tiny punctate hemorrhages
2. 1-3 mm, round and discrete, dark red, purple, or brown in color
3. Due to bleeding from superficial capillaries (non blanching)
4. Dark-skinned people, best visualized on area of lighter pigmentation (abdomen, butt, and volar surface of forearm)
5. Petechiae in mucous membranes: disease process such as thrombocytopenia, subacute microembolism endocarditis, and
other septicemias—not on skin
ii. Purpura:
1. Confluent and extensive patch of petechiae and ecchymoses
2. >3mm flat, red to purple, macular hemorrhage
3. Thrombocytopenia and scurvy
4. Old age: minor trauma causing blood to leak from capillaries and diffuse through dermis
iii. Ecchymosis:
1. Purplish patch resulting from extravasation of blood into skin
2. >3mm diameter
Know changes with aging process within these systems
a.
Slow atrophy of skin structures (loses elasticity, folds, and sags)
i. Epidermis’ outer layer thins and flattens
1. Allows chemicals easier access to body
ii. Dermis thins and flattens and wrinkling occurs
iii. Risk of shearing and tearing injuries increases due to loss of collagen
iv. Decrease in sweat and sebaceous glands
1. Drier skin
2. Risk for heat stroke (thermoregulatory mechanism—sweating—decreases)
b. Senile Lentigines: liver spots
i. Small, flat, brown macules
ii. Circumscribed areas are clusters of melanocytes—appear after extensive sun exposure (forearms and dorsa of hands)—not malignant
(no Tx)
c.
Keratoses:
i. Raised, thickened areas of pigmentation; look crusted, scaly, and warty
ii. Seborrheic Keratosis: look dark, greasy, and “stuck on” – develop mostly on trunk, also on face and hands (non cancerous)
iii. Actinic (senile or solar) keratosis: less common; red-tan scaly plaques, become raised and roughened over years (directly related to
sun exposure)—premalignant (may develop into squamous cell carcinoma)
d. Xerosis: normal drying to aging (decline in sixe, number, and output of sweat and sebaceous glands)
i. Skin itches and looks loose
e.
Acrochordons: skin tags; overgrowths of normal skin—form a stalk and are polyp-like (eyelids, cheeks, neck, axillae, and trunk)
f.
Sebaceous hyperplasia: raised yellow papules with a central depression; common in men; occur over forehead, nose, or cheeks (look pebbly)
g. Hair grays due to decrease in functioning melanocytes (feel thin and fine)
Know common abnormalities reviewed in PowerPoint’s and class discussions (e.g. vitiligo, neuropathy)
a.
What are the skin color variations (e.g. cyanosis, pallor, hyperemia)
a.
Benign pigmented areas:
i. Freckles (ephelides): small, flat macules of brown melanin pigment that occur on sun-exposed skin
ii. Mole (nevus): proliferation of melanocytes, tan to brown in color, flat or raised
1. Characterized by symmetry, size (6mm or less), smooth borders, and single uniform pigmentation
b. Vitiligo: complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and orifices (dark
skinned people more affected)
c.
Pallor: due to loss of oxygenated hemoglobin; skin takes color of collagen
i. Acute stress states (anxiety) due to peripheral vasoconstriction
ii. Cold or cigarette smoking
iii. Edema
iv. Look for pallor in dark-skinned people by the absence of underlying red tones that give brown or black skin its luster
1. Brown skin appears yellowish brown
2. Black skin appears ashen or gray
v. Ashen gray in dark skinned or marked pallor in light skinned occurs with anemia, shock, arterial insufficiency
vi. Pallor with shock presents with rapid HR, oliguria, apprehension, and restlessness
vii. Iron deficiency anemia may show spoon nail
viii. Anemia presents with fatigue, exertional dyspnea, rapid pulse, dizziness, and impaired mental function
ix. Generalized pallor observed in mucous membranes, lips and nail beds
1. Nail beds and conjunctiva (near outer canthus) are the preferred sites for assessing pallor of anemia
d. Erythema: intense redness of skin from excess blood (hyperemia) in the dilated superficial capillaries
i. Fever, local inflammation, or emotional reactions (blushing of cheeks, neck, or upper chest)
1. Fever and inflammation increases skin temp due to rate of blood flow
2. Palpate dark-skinned people for increased warmth, taut or tightly pulled surfaces that are indicative of edema, and
hardened deep tissue or BVs (erythema may not be visual)
ii. Occurs with polycythemia, venous stasis, CO poisoning, and extravascular presence of RBCs (petechiae, ecchymosis, hematoma)
e.
Cyanosis: bluish mottled color signifying decreased perfusion (low tissue O2 blood)
i. Can be nonspecific
ii. Anemia with hypoxemia can present without cyanosis due to low hemoglobin (won’t color skin)
1. Polycythemia produces ruddy blue at all times and may not necessarily be hypoxemic
iii. Dark-skinned Mediterranean people commonly have bluish tone on lips
iv. Indicated hypoxemia and occurs with shock, HF, chronic bronchitis, and congenital heart disease
v. Signs of decreased O2 to brain, changes in LOC, and respiratory distress
f.
Jaundice: indicates rising amount of bilirubin in the blood
6
i.
Noticeable first in hard and soft palate of mouth and sclera
1. Dark-skinned people may have normal yellow subconjunctival fatty deposits in outer sclera
2. Yellow of jaundice extends up to the edge of the iris
ii. Becomes evident on skin of body as serum levels of bilirubin rise
iii. Best assessed in direct natural light
iv. Occurs with hepatitis, cirrhosis, sickle-cell disease, and hemolytic disease of newborns
v. Light or clay-colored stools and dark golden urine often accompany jaundice in both light and dark-skinned people
8. Skin cancer examinations—ABCDE
a.
Asymmetry: not regularly round or oval, two halves of lesion do not look the same
b. Border irregularities: notching, scalloping, ragged edges, poorly defined margins
c.
Color variations: areas of brown, tan, black, blue, red, white, or combo
d. Diameter: greater than 6mm (size of a pencil eraser)
e.
Elevation or Enlargement:
f.
Additional symptoms: rapidly changing lesion, new pigmented lesion, and development of itching, burning, or bleeding in a mole (raise suspicion
of malignant melanoma)
9. Differentiate: senile lentigines, actinic keratoses, squamous cell carcinoma, basal cell carcinoma, and seborrheic keratosis
a.
Senile lentigines:
i. Liver Spots
ii. Small, flat, brown macules
iii. Circumscribed areas are clusters of melanocytes—appear after extensive sun exposure (forearms and dorsa of hands)—not malignant
(no Tx)
b. Actinic keratosis:
i. Red-tan scaly plaques, become raised and roughened over years (directly related to sun exposure)—premalignant (may develop into
squamous cell carcinoma)
c.
Squamous cell carcinoma:
i. Arises from actinic keratosis or denovo
ii. Erythematous scaly patches with sharp margins
iii. > 1cm
iv. Develops central ulcer and surrounding erythema
v. Usually on hands or head, areas of UV exposure; habitually sub-exposed bald scalp
vi. Less common than basal cell carcinoma (grows rapidly)
d. Basal cell carcinoma:
i. Usually starts as a skin-colored papule (may be deeply pigmented) with pearly translucent top and overlying telangiectasia (blood
broken vessels)
ii. Develops rounded, pearly borders with central red ulcer (large open pore with central yellowing)
iii. Most common form a skin cancer (slow but inexorable growth)
iv. Sun exposed face, ears, scalp, shoulders
e.
Seborrheic keratosis:
i. Look dark, greasy, and “stuck on” – develop mostly on trunk, also on face and hands (non cancerous)
f.
Malignant Melanoma:
i. Arise from preexisting nevi (usually)
ii. Usually brown; can be tan, black, pink-red, purple, or mixed pigmentation
iii. Irregular notched borders
iv. May have scaling, flaking, oozing texture
v. Locations:
1. Trunk and back in men and women
2. Legs in women
3. Palms, soles of feet, and nails in Blacks
10. Differentiate arterial and venous peripheral vascular disease –acute and chronic: pain:---noting symptom analysis. (p. 521 in text)
a.
Arterial: s/s of oxygen deficit
i. Chronic Arterial:
1. Location: Deep muscle pain, usually in calf, but may be lower leg or dorsum of foot
2. Character: Intermittent claudication, feels like “cramping,” “numbness and tingling,” “feeling of cold”
3. Onset and Duration: Chronic pain, onset gradual after exertion
4. Aggravating Factors: Activity (walking, stairs); “claudication distance” is specific number of blocks, stairs it takes to
produce pain; elevation (rest pain indicates severe involvement)
5. Relieving Factors: Rest (usually within 2min [ex. Standing]); dangling (severe involvement)
6. Associated Symptoms: Cool, pale skin
7. Those at Risk: Older adults, males > females; inherited predisposition; Hx of HTN, smoking, DM, hypercholesterolemia,
obesity, vascular disease
ii. Acute Arterial:
1. Location: Varies, distal to occlusion, may involve entire leg
2. Character: throbbing
3. Onset and Duration: sudden onset (within 1hr)
4. Aggravating Factors:
5. Relieving Factors:
6. Associated Symptoms: Six Ps: pain, pallor, pulselessness, paresthesia, poikilothermia (coldness), paralysis (indicates
severe)
7. Those at Risk: Hx of vascular surgery; arterial invasive procedure; abdominal aneurysm (emboli); trauma, including
injured arteries; chronic atrial fibrillation
b. Venous: s/s of metabolic waste buildup
i. Chronic Venous:
1. Location: calf, lower leg
2. Character: aching, tiredness, feeling of fullness
7
3.
4.
5.
6.
7.
Onset and Duration: chronic pain, increases at end of day
Aggravating Factors: prolonged standing, sitting
Relieving Factors: elevation, lying, walking
Associated Symptoms: edema, varicosities, weeping ulcers at ankles
Those at Risk: job with prolonged standing or sitting; obesity; pregnancy; prolonged bed rest; Hx of HF, varicosities, or
thrombophlebitis; veins crushed by trauma or surgery
ii. Acute Venous:
1. Location: calf
2. Character: intense, sharp; deep muscle tender to touch
3. Onset and Duration: sudden onset (within 1hr)
4. Aggravating Factors: pain may increase with sharp dorsiflexion of foot
5. Relieving Factors:
6. Associated Symptoms: red, warm, swollen leg
7. Those at Risk:
11. Describe arterial pulses—variations in pulse contour–and grading system
a.
Temporal: palpated in front of the ear
b. Carotid: palpated in the groove b/t the sternomastoid muscle and trachea
c.
Brachial: runs in the biceps-triceps furrow of upper arm and surfaces at the antecubital fossa in the elbow medial to the biceps tendon
i. Both should be equal
d. Ulnar: medial to the ulna; deeper and often difficult to feel
e.
Radial: medial to radius at the wrist
i. 3+: increased, full, bounding (exercise, anxiety, fever, anemia, hyperthyroidism)
ii. 2+: normal
iii. 1+: weak (shock and PAD)
iv. 0: absent
f.
Modified Allen test: evaluate the adequacy of collateral circulation before cannulating the radial artery
i. Firmly occlude both ulnar and radial arteries (11lbs of pressure) while person makes a fist several times (causes hands to blanch)
ii. Person opens hand without hyperextending it
iii. Release pressure on the ulnar artery while maintaining pressure on the radial artery
iv. Palm should blush with adequate circulation
v. Pallor or sluggish return suggests occlusion of the collateral artery flow
g. Femoral: just below the inguinal ligament halfway b/t the pubis and anterior superior iliac spine (to assess, have person bend knee to the side—
froglike position)
i. Press firmly and release slowly—note pulse tap
ii. If pulse is weak or diminished, auscultate for bruit
1. Bruit occurs with turbulent blood flow—indicates partial occlusion
h. Popliteal: lower thigh behind knee
i. Palpate by extending the leg (but relaxed), anchor thumb on knee and curl fingers around popliteal fossa; press fingers forward hard to
compress artery against the bone
i.
Dorsalis pedis: dorsum of foot
j.
Posterior tibial: travels down behind the medial malleolus
k. Ankle-Brachial Index (ABI):
i. Ankle systolic / Arm systolic = ____%
1. Normal 1.0 – 1.02
2. < 0.90 indicates PAD
a.
0.90 – 0.70: mild claudication
b. 0.70 – 0.40: moderate to severe claudication
c.
0.40 – 0.30: severe claudication, usually with rest pain except in the presence of diabetic neuropathy
d. <0.30: ischemia, with impending loss of tissue
l.
Pulse Contour:
i. 1+ (weak, thready pulse)
1. Hard to palpate, need to search for it, may fade in and out, easily obliterated by pressure
2. Associated with decreased CO, peripheral arterial disease, aortic valve stenosis
ii. 3+ (full, bounding)
1. Easily palpable, pounds under fingertips
2. Associated with hyperkinetic states (exercise, anxiety, fear), anemia, hyperthyroidism
iii. 3+ (water-hammer – Corrigan)
1. Greater than normal force, then collapses suddenly
2. Associated with aortic valve regurgitation, patent ductus arteriosus
iv. Pulsus Gigeminus:
1. Rhythm is coupled, every other beat comes early, or normal beat followed by premature beat; force of premature beat is
decreased because of shortened cardiac filling time
2. Associated with conduction disturbance (PVCs, PACs)
v. Pulsus Alternans:
1. Rhythm is regular, but force varies with alternating beats of large and small amplitude
2. When HR is normal, pulsus alternans occurs with severe left vent failure, which in turn is due to ischemic heart disease,
valvular heart disease, chronic hypertension, or cardiomyopathy
vi. Pulsus Paradoxus:
1. Beats have weaker amplitude with inspiration, stronger with expiration; best determined during BP measurements; reading
decreases (>10mmHg) during inspiration and increases with expiration
2. A common finding in cardiac tamponade (pericardial effusion in which high pressure compresses the heart and blocks
CO); also in severe bronchospasms of acute asthma
vii. Pulsus Bisferiens
1. Each pulse has two strong systolic peaks, with a dip in between; best assessed at the carotid artery
8
2. Associated with aortic valve stenosis plus regurgitation
12. Describe lymph nodes examined—and if felt how are they analyzed
a.
Cervical nodes: drain the head and neck
b. Axillary nodes: drain the breast and upper arms
c.
Epitrochlear nodes: lie in the antecubital fossa (depression above and behind the medial condyle of the humerus) and drain the hand and lower
arm
i. Assess by shaking hands with the person and reaching your other hand under the person’s elbow to the groove b/t the biceps and
triceps muscles (above the medial condyle)
ii. Not palpable normally
iii. Enlargement signifies infection of hand or forearm; generalized lymphadenopathy (lymphoma, chronic lymphocytic leukemia,
sarcoidosis, infection, mononucleosis)
d. Inguinal nodes: located in the groin and drain most of the lymph of the Les, external genitalia, and the anterior abdominal wall
i. Not unusual to find palpable nodes that are small (1cm or less), moveable, and nontender
ii. Abnormal: enlarged, tender, or fixed in area
13. Describe signs/symptoms of:
a.
Lymphedema:
i. High-protein swelling of the limbs (commonly due to breast cancer Tx)
1. Surgical removal of lymph nodes or damage to nodes and vessels with radiation impedes drainage of lymph (protein rich
lymph builds up in interstitial spaces, further raising local colloid oncotic pressure—promotes more fluid leakage)
2. Stagnant lymphatic fluid increases risk for infection, delayed wound healing, chronic inflammation, and fibrosis of
surrounding tissue
ii. Early symptoms: tired, thick, heavy arm (self-reported); jewelry too tight; swelling; tingling
iii. Objective data: unilateral swelling, non-pitting brawny edema, with overlying skin induration
b. Claudication:
i.
c.
Venous insufficiency:
i.
d. Raynauds disease:
i. Episodes of abrupt, progressive tricolor change of the fingers in response to cold, vibration, or stress
ii. Progression: white (pallor) due to arteriospasm and resulting deficit in supply; cyanosis from slight relaxation of the spasm that allows
a slow trickle of blood through the capillaries and increased oxygen extraction of hemoglobin; red (rubor) in heel of hand due to return
of blood into the dilated capillary bed or reactive hyperemia
iii. S/S: cold, numbness, or pain along with pallor or cyanosis stage; then burning, throbbing pain, swelling, along with rubor; lasts
minutes to hrs.; occurs bilaterally; smoking and drugs can increase symptoms
e.
DVT:
i. Thrombus that causes inflammation, blocked venous return, cyanosis, and edema
ii. Subjective: sudden onset of intense, sharp, deep muscle pain; may increase with sharp dorsiflexion of foot
iii. Objective: Increased warmth; swelling; redness; dependent cyanosis is mild or may be absent; tender to palpation; positive Homan’s
in some cases
f.
Venous stasis ulcer:
i. Usually at medial malleolus (due to bacterial invasion of poorly drained tissues); occur after DVT or chronic incompetent valves in
deep veins
ii. Subjective: Aching pain in calf or lower leg; worse at end of day; worse with prolonged standing or sitting
iii. Objective: Firm, brawny edema; coarse, thickened skin; pulses normal; brown pigment discoloration (RBC breakdown, leaving
hemosiderin [iron deposits]); petechiae; weepy, pruritic stasis dermatitis may be present
g. Arterial ischemic ulcer:
i. Usually occurs on tips of toes, metatarsal heads, heals, and lateral malleoli of ankles (pale ischemic base, well-defined edges, no
bleeding)
ii. Unilateral cool foot or leg or a sudden temperature drop as you move down the leg occurs with arterial deficit
iii. Buildup of fatty plaques on intima (atherosclerosis) plus hardening and calcification of arterial wall (arteriosclerosis)
iv. Subjective: deep muscle pain in calf or food, claudication (pain with walking), pain at rest indicates worsening of condition
v. Objective: coolness, pallor, elevation pallor, and dependent rubor; diminished pulses; systolic bruits; signs of malnutrition (thin, shiny
skin; thick-ridged nails; atrophy of muscles); distal gangrene
h. Varicose veins:
i. Incompetent valves permit reflux of blood, producing dilated, tortuous veins
ii. Subjective: Aching, heaviness in calf, easy fatigability, night leg or food cramps
iii. Objective: Dilated, tortuous veins
i.
Changes noted with diabetes:
i. Hastens changes described with ischemic ulcer, with generalized dysfunction in all arterial areas:
1. Peripheral (diabetic neuropathy), coronary, cerebral, retina, kidney
ii. Ulcers may go unnoticed
iii. Pain and sensation are decreased, surrounding skin is calloused
THORAX/LUNGS (Ch. 18):
1.
Know anatomy and physiology
a.
Angle of Louis: second rib and second ICS
b. Vertebra Prominens: C7
c.
Costal angle (anterior): 90˚
d. Inferior angle of scapula: posterior ribs 7 or 8
e.
Right lung: 3 lobes
f.
Left lung: 2 lobes
g. Left lung has no middle lobe
h. Anterior chest contains mostly upper and middle lobe with very little lower lobe
9
2.
i.
Posterior chest contains almost all lower lobe
j.
Tracheal bifurcation: anteriorly at sternal angle; posteriorly at level of T4 or T5
Know order of physical examination and order of what is done in each section AND HOW IT IS DONE
a.
Subjective data:
i. Couch
1. Acute lasts 2-3 wks.
a.
Continuous throughout day (resp infection)
b. Afternoon/evening (chem exposure)
c.
Night (postnasal drip, sinusitis)
2. Chronic >2months
a.
Morning (chronic bronchial inflammation of smokers)
b. Chronic bronchitis (Hx of productive cough for 3months of the year for 2yrs)
3. Hemoptysis
4. Sputum
a.
White or clear: colds, bronchitis, viral infection
b. Yellow or green: bacterial infection
c.
Rust colored: TB, PNA
d. Pink, frothy: pulmonary edema; sympathomimetic meds
5. Characteristics:
a.
Hacking: mycoplasma PNA
b. Dry: early HF
c.
Barking: croup
d. Congested: colds, bronchitis, PNA
ii. SOB
1. Determine level of activity that precipitates SOB (# of blocks walked or stairs climbed)
2. Orthopnea: difficulty breathing when supine (# of pillows needed to achieve comfort)
3. Paroxysmal nocturnal dyspnea (awakening from sleep with SOB—need to be upright to achieve comfort
4. Diaphoresis; cyanosis signals hypoxia
5. Asthma attack and precipitating factor (allergens, extreme cold, anxiety)
6. Assess coping strategies and need for teaching
7. Asses ADLs and its affect on them
iii. CP
1. CP of thoracic origin occurs with muscle soreness from coughing or inflammation of pleura overlying PNA (distinguish
from other causes—cardiac or heartburn)
iv. Hx of resp infections
v. Smoking: state number of packs per year and # of years smoking
vi. Environment exposure: pollution; farmers at risk for grain inhalation and pesticides
1. Symptoms: cough, SOB; CO exposure = dizziness, HA, fatigue; Sulfur dioxide = cough, congestion
vii. Self care: flu vaccine; TB test
b. Objective
i. Posterior thorax:
1. Inspection:
a.
Thoracic cage:
i. Shape and configuration
1. Spinous process should appear in a straight line; thorax symmetric, elliptical shape,
downward sloping ribs, 45˚ relative to spine; scapulae placed symmetrically in each
hemithroax
2. AP diameter < transverse diameter (1:2 or 5:7)
3. Neck muscles and traps developed normally for age and occupation (hypertrophy in
COPD)
ii. Position
1. Relaxed posture with arms comfortably at side or in lap
2. COPD = tripod (arms on knees and leaning forward—allows for aid from rectus
abdomins, intercostals, and accessory muscles)
iii. Skin color and condition
1. Consistent with genetic background; no cyanosis or pallor
2. Palpation:
a.
Confirm symmetric expansion: hands placed on posterolateral chest walls with thumbs at the level of T9 or T10
(small fold of skin pinched b/t thumbs)
i. Unequal occurs with marked atelectasis, lobar PNA, pleural effusion; fractured ribs; pneumothorax
ii. Pain with inflammation of pleurae
b. Tactile fremitus:
i. Palpable vibration
ii. Use palmar base of fingers or ulnar edge while pt repeats 99 or blue moon
iii. Start at apex of lungs from one side to the other
iv. Look for symmetry
1. Between scapulae-may feel stronger on right side (closer to bronchial bifurcation)
2. Fremitus normally decreases from scapulae (bronchi close to chest wall) downward due
to more tissue mass
3. Take into account size of pt and pitch of voice (low pitch = more fremitus)
4. Decreased fremitus: obstruction (obstructed bronchus, pleural effusion or thickening,
pneumothorax, or emphysema)
5. Increased fremitus: compression or consolidation of lung tissue (lobar PNA) when
bronchus is patent and consolidation extends to lung surface
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6.
7.
8.
3.
Rhonchal fremitus: thick bronchial secretions
Pleural friction fremitus: inflammation of the pleura
Crepitus: coarse, crackling sensation palpable over skin surface (subcutaneous
emphysema—air escapes lungs and enters subQ tissue or after open thoracic injury or
surgery)
c.
Palpate for tenderness, moisture, temp, lumps or masses, lesions
3. Percussion:
a.
Percuss in 5cm intervals avoiding bone
b. Resonance: low-pitched, clear, hollow sound in healthy lungs
c.
Hyperresonance: low-pitched booming sound with too much air present (emphysema or pneumothorax)
d. Dull: soft, muffled signals abnormal density with PNA, pleural effusion, atelectasis, or tumors
e.
Percussion notes must be 2-3cm wide to yield abnormality
f.
Percussion only penetrates 5-7cm deep
g. Diaphragmatic excursion: map by percussing lower lung border (inspiratory and expiratory)
i. Percuss on exhalation down scapular line until you hear dullness – may be higher on right side (12cm) due to liver
ii. Percuss on inhalation and continue percussing to dullness and mark
iii. Excursion should be 3-5cm bilaterally (may ne 7-8cm in well conditioned person)
iv. Absence of excursion in pleural effusion or atelectasis of lower lobes
4. Auscultation:
a.
Use diaphragm to listen to full respiration in each location
b. Locations:
i. Posterior: apex to C7 to bases (around T10)
ii. Lateral: axilla to 7th or 8th rib
ii. Anterior thorax:
1. Inspect:
a.
Shape and config
i. Ribs sloping downward with symmetric ICS
ii. Costal angle ≤90˚
1. Barrel chest >90˚ costal angle
iii. Normal development of abdominal muscles
1. Hypertrophy occurs with emphysema
b. Facial expression
i. Relaxed and benign, indicating unconscious breathing
ii. COPD
1. Tense, strained, tired face
2. Pursed lips allowing air to be exhaled slowly—narrow opening creates pressure in
bronchial tree and fewer airways collapse
c.
LOC:
i. AAOx4
d. Skin color and condition
i. Nail beds free of cyanosis and pallor; normal configuration
1. Clubbing of distal phalanx occurs with chronic respiratory disease
ii. No lesions
1. Cutaneous angioms (spider nevi) associated with liver disease or portal HTN may be
evident on chest
e.
Respirations (quality): automatic and effortless, regular, even, no noise; symmetrical expansion of chest during
inspiration; no lag on inspiration
i. Noisy=asthma or chronic bronchitis
ii. Unequal expansion occurs when part of lung is onstructed or collapsed (PNA) or when guarding to
avoid postop incisional pain or pleurisy pain
iii. Retractions
1. No presence on inspiration
2. Suggest obstruction of resp tract or increased inspiratory effort (at with atelectasis)
iv. Bulging indicates trapped air as in the forced expiration with emphysema or asthma
2. Palpate
a.
Symmetric expansion:
i. Hands on anterolateral wall with thumbs along costal margin, pointing inward toward xiphoid
process (symmetrical expansion on inspiration)
ii. Emphysema: wide costal angle with little inspiratory variation
iii. Atelectasis, PNA, postop guarding: lag in expansion
b. Tactile fremitus
i. Begin at apex and repeat 99
ii. Female breast tissue dampens sound
c.
Palpate chest wall for tenderness, lumps and masses, skin turgor, temp, moisture
3. Percussion
a.
Begin at apices (supraclavicular) continuing down within ICS
b. Note borders of cardiac dullness
c.
Liver: dullness in 5th ICS in the right midclavicular line
d. Tympany over left gastric space
4. Auscultate
5. Forced expiratory time: should be ≤4sec (≥6sec = obstructive lung disease
Know changes with aging process within these systems
a.
Costal cartilage becomes calcified—produces a less mobile thorax
11
b.
c.
d.
e.
f.
g.
h.
i.
4.
5.
6.




Resp muscle strength decreases after age 50 and continues to decrease into 70s
Lungs decrease in elasticity (less distensible and lessening their tendency to collapse and recoil
More ridged and harder to inflate
Increase in small airway closure (decreased vital capacity—max volume of air expelled after maximum filling)
Increased residual volume (amount of air remaining in lungs after forced expiration)
Gradual loss of intraalveolar septa and decreased number of alveoli (less surface are for gas exchange)
Less ventilation with closure of airways—increased risk for dyspnea with exertion
Increased risk for pulmonary postop complications (atelectasis and infection—decreased ability to cough, a loss of protective airway reflexes, and
increased secretions)
DESCRIBE “NORMAL LUNG SOUNDS”—VESICULAR, BRONCHOVESICULAR, BRONCHIAL and where should they be heard
a.
Bronchial: pitch high, amplitude loud; duration: inspiration > expiration; quality harsh, hollow, tubular; Location: trachea and larynx
b. Bronchovesicular: pitch and amplitude moderate; duration: inspiration = expiration; quality mixed; location over bronchi where fewer alveoli
are located; posterior b/t scapulae especially on right, anterior around upper sternum in 1st and 2nd ICS
c.
Vesicular: pitch low; amplitude soft; duration: inspiration > expiration; quality: rustling like the sound of wind in trees; location over peripheral
lung fields where air flow through smaller bronchioles and alveoli
Describe added voice sounds and adventitious lung sounds—when may you hear them—what conditions
a.
Voice sounds (should be soft, muffled, and indistinct—pathology that increases lung density enhances transmission of voice sounds) – normally
used if lung pathology is suspected- not routine
i. Bronchophony: ask the person to repeat “ninety-nine” while you listen with the stethoscope over the chest wall; listen especially if you
suspect pathology
1. Normal finding: normal voice transmission is soft, muffled, and indistinct; you can hear sound through the stethoscope but
cannot distinguish exactly what is being said
2. Abnormal finding: pathology that increases lung density will enhance transmission of voice sounds; you can auscultate a
clear “ninety-nine”; the words are more distinct than normal and sound close to your ear
ii. Egophony: auscultate the chest while the person phonates a long “ee-ee-ee-ee” sound
1.
Normal finding: normally, you should hear “eeeee” through stethoscope
2. Abnormal finding: over area of consolidation or compression, the spoken “eeee” sound changes to a bleating long “aaaa”
sound
iii. Whispered Pectoriloquy: ask the person to whisper a phrase like “one-two-three” as you auscultate
1. Normal finding: the normal response is faint, muffled, and almost inaudible
2. Abnormal finding: with only small amounts of consolidation, the whispered voice is transmitted very clearly and distinctly,
although still somewhat faint; it sounds as if the person is whispering right into your stethoscope, “one-two-three”
b. Adventitious sounds:
i. Discontinuous Sounds: those that are discrete, crackling sounds
1. Crackles – fine (formerly called rales): discontinuous, high-pitched, short crackling, popping sounds heard during
inspiration that are not cleared by coughing
a.
Clinical ex: pneumonia, CHF, COPD
2. Crackles – coarse (coarse rales): loud, low-pitched bubbling and gurgling sounds that start in early inspiration and may be
present in expiration; may decrease somewhat by suctioning or coughing but will reappear shortly
a.
Clinical ex: pulmonary edema, pneumonia, pulmonary fibrosis
3. Atelectatic crackles: short, popping, crackling sounds that sound like fine crackles but do not last and are not pathologic;
disappear after first few breaths or a cough; heard in periphery (dependent portions of lungs)
a.
Clinical ex: aging adults; bedridden persons or in persons just aroused from sleep
4. Pleural friction rub: a very superficial sound that is coarse and low pitched; it has a grating quality as if two piece of
leather are being rubbed together; sounds just like crackles, but close to the ear; sounds louder if you push the stethoscope
harder onto chest wall
a.
Clinical ex: pleuritis, accompanied by pain with breathing (rub disappears after a few days if pleural fluid
accumulates and separates pleurae)
ii. Continuous Sounds: these are connected, musical sounds
1. Wheeze – high pitched: high-pitched, musical squeaking sounds that sound polyphonic; predominant in expiration but may
occur in both
a.
Clinical ex: diffuse airway obstruction from acute asthma or chronic emphysema
2. Wheeze – low-pitched: low-pitched; monophonic single note, musical snoring, moaning sounds; heard throughout the
cycle
a.
Clinical ex: bronchitis, single bronchus obstruction from airway tumor
3. Stridor: high-pitched, monophonic, inspiratory, crowing sound, louder in neck than over chest wall
a.
Clinical ex: coup and acute epiglottitis in children, and foreign inhalation, obstructed airway may be lifethreatening
Describe respiratory patterns and in what conditions may they be heard
Normal Adult:
o
Rate: 10-20 breaths per minute
o
Depth: 500-800mL
o
Pattern: even
o
The ratio of pule to respirations is fairly constant, about 4:1, both values increase as a normal response to exercise, fear, or fever
o
Depth: air moving in and out with each respiration
Sigh: occasional sighs punctuate the normal breathing pattern and are purposeful to expand alveoli; frequent sighs may indicate emotional dysfunction; may
also lead to hyperventilation and dizziness
Tachypnea: rapid, shallow breathing; increased rate, >24 per minute; normal response to fever, fear, or exercise; rate also increases with respiratory
insufficiency, pneumonia, alkalosis, pleurisy, and lesions in the pons
Hyperventilation: increase in both rate and depth; normally occurs with extreme exertion, fear, or anxiety
o
DKA
o
Hepatic coma
o
Salicylate overdose
o
Alteration in blood gas concentration
12





7.
o
Blows off CO2 causing a decreased level in the blood
Bradypnea: slow breathing; a decreased but regular rate (<10 per minute)
o
Drug induced depression
o
Increased ICP
o
Diabetic coma
Hypoventilation: irregular shallow pattern caused by an overdose of narcotics or anesthetics; may also occur with prolonged bedrest or conscious splinting
of the chest to avoid respiratory pain
Cheyne-Stokes Respiration: a cycle in which respirations gradually wax and wane in a regular pattern, increasing in rate and depth and then decreasing;
lasts 30-45 seconds with periods of apnea (20 seconds) alternating the cycle
o
Severe heart failure
o
Renal failure
o
Meningitis
o
Drug overdose
o
Increased ICP
o
Occurs normally in infants and aging persons during sleep
Biot’s Respiration: similar to Cheyne-Stokes, except that the pattern is irregular; a series of normal respirations is followed by a period of apnea
o
Head trauma
o
Brain abscess
o
Heat stroke
o
Spinal meningitis
o
Encephalitis
Chronic Obstructive Breathing: normal inspiration and prolonged expiration to overcome increased airway resistance
o
COPD
o
Any situation calling for increased heart rate (exercise) may lead to dyspneic episode (air trapping) because the person does not have enough time
for full expiration
a.
Describe signs and symptoms associated with COPD, bronchitis, emphysema, pulmonary effusion, sarcoidosis, consolidation, pulmonary embolism,
atelectasis, asthma, lobar pneumonia, pneumothorax, tuberculosis ARDS-acute respiratory distress syndrome
8. Chronic Obstructive Pulmonary Disease (COPD):
9. Bronchitis: proliferation of mucus glands in the passageways, resulting in excessive mucus secretion; inflammation of bronchi with partial obstruction
of bronchi by secretions or constrictions
a. Inspection: hacking, rasping cough productive of thick mucoid sputum
b. Palpation: tactile fremitus normal
c.
Percussion: resonant
d. Auscultation: normal vesicular; voice sounds normal
e.
Adventitious sounds: crackles over deflated areas, may have wheeze
10. Emphysema: caused by destruction of pulmonary connective tissue; characterized by permanent enlargement of air sacs distal to terminal bronchioles;
hyperinflated lung
a. Inspection: increased AP diameter (barrel chest); use of accessory muscles to aid respiration; tripod position; SOB, especially on exertion
b. Palpation: decreased tactile fremitus and chest expansion
c.
Percussion: hyperresonant, decreased diaphragmatic excursion
d. Auscultation: decreased breath sounds; may have prolonged expiration; muffled heart sounds resulting from overdistention of lungs
e.
Adventitious sounds: usually none; occasionally wheeze
11. Pulmonary Effusion: collection of excess fluid in the intrapleural space, with compression of overlying lung tissue; may contain watery capillary
fluid, protein, purulent matter, blood, or milky lymphatic fluid
a. Inspection: increased respirations, dyspnea; may have dry couch, tachycardia, cyanosis, abnormal distention
b. Palpation: tactile fremitus decreased or absent; tracheal shift away from affected side; chest expansion decreased on affected side
c.
Percussion: dull to flat; no diaphragmatic excursion on affected side
d. Auscultation: breath sounds decreased or absent; voice sounds decreased or absent; when remainder of lung is compressed near effusion,
may have bronchial breath sounds over the compression
e.
Adventitious sounds: none
12. Sarcoidosis:
13. Consolidation:
14. Pulmonary Embolism: undissolved materials originating in legs or pelvis detach and travel through venous system returning blood to right heart and
lodge to occlude pulmonary vessels
a. Subjective: chest pain, worse on deep inspiration, dyspnea
b. Inspection: apprehensive, restless, anxiety, mental status changes, cyanosis, tachypnea, cough, hemoptysis, PaO2 <80% on pulse ox, ABGs
show respiratory alkalosis
c.
Palpation: diaphoresis, hypotension
d. Auscultation: tachycardia, accentuated pulmonic component of S2 heart sound
e.
Adventitious sounds: crackles, wheezes
15. Atelectasis (Collapse): collapsed shrunken section of alveoli or an entire lung as a result of 1. Airway obstruction 2. Compression on the lung 3. Lack
of surfactant
a. Inspection: cough; lag on expansion on affected side; increased respiratory rate and pulse; possible cyanosis
b. Palpation: chest expansion decreased on affected side; tactile fremitus decreased or absent over area; with large collapse, tracheal shift
toward affected side
c.
Percussion: dull over area (remainder of thorax sometimes may have hyperresonant note)
d. Auscultation: breath sounds decreased vesicular or absent over area; voice sounds variable, usually decreased or absent over affected area
e.
Adventitious sounds: none if bronchus is obstructed; occasional fine crackles if bronchus is patent
16. Asthma: an allergic hypersensivity to certain inhaled allergens, irritants, microbes, stress, or exercise that produces a complex response characterized
by bronchospasm and inflammation
a. Inspection: during severe attack: increased respiratory rate, SOB with audible wheeze, use of accessory neck muscles, cyanosis,
apprehension, retraction of intercostal spaces, expiration labored, prolonged; when chronic, may have barrel chest
b. Palpation: tactile fremitus decreased, tachycardia
13
c.
Percussion: resonant; may be hyperresonant if chronic
d. Auscultation: diminished air movement; breath sounds decreased, with prolonged expiration, voice sounds decreased
e.
Adventitious sounds: bilateral wheezing on expiration, sometimes inspiratory and expiratory wheezing
17. Lobar Pneumonia: infection in lung parenchyma leaves alveolar membrane edematous and porous, so RBCs and WBCs pass from blood to alveoli
a. Inspection: increased respiratory rate; guarding and lag on expansion on affected side; children – sternal retraction, nasal flaring
b. Palpation: chest expansion decreased on affected side; tactile fremitus increased if bronchus patent; decreased if bronchus obstructed
c.
Percussion: dull over lobar pneumonia
d. Auscultation: breath sounds louder with patent bronchus, voice sounds have increased clarity
e.
Adventitious sounds: crackles, fine to medium
18. Pneumothorax: free air in pleural space causes partial or complete lung collapse; spontaneous, traumatic, or tension
a. Inspection: unequal chest expansion; if large, tachypnea, cyanosis, apprehension, bulging in interspaces
b. Palpation: tactile fremitus decreased or absent; tracheal shift to opposite side (unaffected side); chest expansion decreased on affected side;
tachycardia, decreased BP
c.
Percussion: hyperresonant; decreased diaphragmatic excursion
d. Auscultation: breath sounds decreased or absent; voice sounds decreased or absent
e.
Adventitious sounds: none
19. Tuberculosis:
a. Subjective: initially asymptomatic, showing as positive skin test or on x-ray film; progressive TB involves weight loss, anorexia, easy
fatigability, low-grade afternoon fevers, night sweats; may have pleural effusion, recurrent lower respiratory infections
b. Inspection: cough initially nonproductive; later productive of purulent, yellow-green sputum, may be blood tinged; dyspnea, orthopnea,
fatigue, weakness
c.
Palpation: skin moist at night from night sweats
d. Percussion: resonant initially; dull over any effusion
e.
Auscultation: normal or decreased vesicular breath sounds
f.
Adventitious sounds: crackles over upper lobes common, persist following full expiration and cough
20. Acute Respiratory Distress Syndrome (ARDS): an acute pulmonary insult damages alveolar capillary membrane, leading to increased permeability
of pulmonary capillaries and alveolar epithelium and to pulmonary edema
a. Subjective: acute onset of dyspnea, apprehension
b. Inspection: restlessness; disorientation; rapid, shallow breathing; productive cough, thin, frothy sputum; retractions of intercostal spaces and
sternum; decreased PaO2, blood gases show respiratory alkalosis, x-ray films show diffuse pulmonary infiltrates, a late sign is cyanosis
c.
Palpation: hypotension
d. Auscultation: tachycardia
e.
Adventitious sounds: crackles, rhonchi
21. Know causes for increased and decreased breath sounds
a.
Breath sounds:
i. Decreased:
1. Bronchial tree obstruction by secretions, mucus plug, or foreign body
2. Emphysema as a result of loss of elasticity in lung fibers and decreased force of inspired air; lungs are already
hyperinflated so inhaled air does not make much noise
3. When anything obstructs transmission of sound b/t lungs and stethoscope (pleurisy or pleural thickening, or air
[pneumothorax] or fluid [pleural effusion] in pleural spaces)
ii. Increased:
1. Sounds are louder then they should be (bronchial sounds are abnormal when heard in peripheral lung fields—high pitched
tubular quality, with prolonged expiratory phase and a distinct pause b/t inspiration and expiration)
a.
Sound very close to stethoscope as if they were right in the tubing of your ear
b. Occur when consolidation (PNA) or compression (fluid in intrapleural space) yields a dense lung area that
enhances the transmission of sound from the bronchi
22. KNOW LINES OF REFERENCE for each section: ANTERIOR, POSTERIOR, AND AXILLARY
a.
Anterioor:
i. Midclavicular line: midpoint between sternoclavicular and acromioclavicular joints
ii. Midsternal line: sternum
b. Posterior:
i. Vertebral (midspinal) line: vertebrae
ii. Scapular line: aligns with inferior angle of scapula
c.
Lateral:
i. Anterior axillary: extends down from the anterior axillary fold where the pectoralis major inserts
ii. Midaxillary: Between anterior and posterior
iii. Posterior axillary: continues down from where the latissimus dorsi muscle inserts
23. KNOW LOBES OF LUNGS—AND WHERE ANATOMICALLY THEY START AND STOP
a.
Apex of the lungs: 3-4cm above inner third of the clavicles
b. Base: rests on diaphragm at about the 6th rib in the midclavicular line
c.
Lateral lung: extends from apex of axilla down to 7th or 8th rib
d. Posterior:
i. Apex: C7 or T1
ii. Base: T10
iii. On inspiration, lower lung border drops to T12
e.
Anterior:
i. R and L lungs: Oblique fissure: crosses 5th rib in midaxillary line and terminates at the 6th rib in the midclavicular line
ii. R Lung: horizontal fissure (divides right upper and middle lobes) extends from the 5th rib in the right midaxillary line to the 3rd
intercostal space or 4th rib at the right sternal border
f.
Posterior:
i. Upper lobes: T1 to T3-4
ii. T3-4 down to Base: T10
g. Lateral:
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Upper lobe: apex of the axilla down to the horizontal fissure at the 5th rib (horizontal fissure: 5th rib mid axillary line to 4th rib
midsternal line)
ii. Right middle lobe: horizontal fissure down and forward to the 6th rib at the midclavicular line
iii. Right lower lobe: continues from the 5th rib to the 8th rib in the midaxillary line (oblique fissure: 4th rib in the posterior axillary line to
the 6th rib at the miclaviclar line)
iv. Left upper lobe: apex of axilla down to 5th rib at the midaxillary line
24. Discuss abnormal shapes of chest (e.g. scoliosis, kyphosis) and their impact upon bodily systems (e.g. respiratory, cardiac)
a.
Normal: thorax elliptical w/ AP to transverse diameter 1:2 or 5:7; ribs downward sloping
b. Barrel chest: equal AP to transverse diameter w/ ribs horizontal (associated with normal aging and COPD with hyperinflation of lungs
c.
Pertus excavatum: markedly sunken sternum and adjacent cartilage (funnel breast)—depression begins at 2nd ICS, becoming depressed most at
junction of xiphoid and body of sternum—more noticeable on inspiration (congenital, usually not symptomatic)
d. Pertus carinatum: forward protrusion of sternum, ribs sloping back at either side and vertical depression along costochrondral junctions (pigeon
breast)—minor deformity that requires no Tx
e.
Scoliosis: S-shaped curvature of thoracic and lumbar spine with vertebral rotation—mild deformities are asymptomatic—severe (>45˚ deviation)
may reduce lung volume and pt at risk for impaired cardiopulmonary function
f.
Kyphosis: exaggerated posterior curvature of thoracic spine (humpback) that causes significant back pain and limited mobility—severe
deformities impair cardiopulmonary function
i. If neck muscles are strong, compensation occurs by hyperextension of the head to maintain level of vision
ii. Associated with aging (dowager’s hump) of postmenopausal osteoporotic women; may be associated with physical fitness
(inadequate)
i.
ABDOMEN (Ch. 21):
1.
2.
Know anatomy and physiology
a.
Know order of physical examination and order of what is done in each section AND HOW IT IS DONE
a.
Inspection:
i. Contour: flat, scaphoid (caved in), rounded, protuberant; describes nutritional state
1. Abnormal
a.
Bulges or masses
b. Hernia: protrusion of abdominal viscera through abnormal opening in muscle wall
ii. Symmetry: note any bulging, visible masses, or asymmetric shape by shining a light across
iii. Umbilicus: normally midline or inverted; no signs of discoloration, inflammation, or hernia; no redness or crust
1. Everted with ascites or underlying mass
2. Deeply sunken with obesity
3. Enlarged, everted with hernia
4. Bluish periumbilical color with intra-abdominal bleeding (Cullen sign)—rare
iv. Skin: smooth and even, homogenous color (good to judge pigment—protected from sun)
1. Note scars: may give evidence of underlying adhesions and excess fibrous tissue
2. Redness: localized inflammation
3. Ascites: skin glistening and taut; striae
4. Striae: purple-blue with Cushing’s
5. Veins usually not seen
a.
Prominent dilated veins occurs with portal HTN, cirrhosis, ascites, or venal caval obstruction; visible with
malnutrition
6. Turgor: good=healthy nutrition; poor=dehydration, accompanying GI disease
v. Pulsation or movement: normal to see pulsations from aorta and respiratory movement (males); peristalsis in thin persons
1. Marked aortic pulse with widened pulse pressure (HTN, aortic insufficiency, thyrotoxicosis; aortic aneurysm)
2. Marked visible peristalsis, together with distention, indicates intestinal obstruction
vi. Hair distribution: diamond shape in males and inverted triangle in females
vii. Demeanor (calm and relaxed or restless and constant turning (colicky pain of gasteroenteritis or bowel obstruction); absolute stillness
occurs with pain of peritonitis; knees flexed, facial grimacing, and rapid uneven respirations indicate pain
b. Auscultate: (use diaphragm—high pithed)
i. Normal: high pitched, gurgling, cascading sounds, occurring irregularly anywhere from 5-30/min
ii. Borborygmus: hyperactive stomach growling (normal)
iii. 5min must go by if no sound is heard to declare absent bowel sounds
iv. Hyperactive: high-pithed, rushing, tinkling sound
v. Hypoactive: follows abdominal surgery or inflammation (peritonitis)
vi. Vascular sounds:
1. Bruits over aorta, renal arteries, iliac, and femoral arteries (esp in HTN)
2. Normally no sound present (may have a normal bruit originating at celiac artery if <40)
3. Systolic bruit is a pulsatile blowing sound and occurs with stenosis or occlusion of an artery
4. Venous hum and peritoneal friction rub are rare
c.
Percussion: (general tympany, liver span, and splenic dullness)
i. General tympany:
1. Over all 4 quads to determine prevailing amount of tympany and dullness (clockwise)
a.
Tympany predominates d/t air in intestines rising to surface while supine
b. Dullness occurs over distened bladder, adipose tissue, fluid, or masses
c.
Hyperresonance is present with gaseous distention
2. Liver span:
a.
Map boundaries of liver
i. Height of liver in right midclaviular line by beginning in area of lung resonance until dullness
(mark); percuss up from tympany of abdomen until dullness (normal distance between 2 marks is 612cm)
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1. 10.5 for males; 7 for females
Splenic dullness: percuss for dull note from the 9th to 11th ICS just behind the left midaxillary line (area of dullness not
normally wider than 7cm
a.
Dullness forward of the midaxillary line indicates splenic enlargement (mono, trauma, infection)
ii. Costoceterbral angle tenderness (indirect fist percussion causes tissues to vibrate instead of producing a sound)
1. Assess kidneys: place hand over 12th rib at costovertebral angle on back and thump with fist of other hand—normally a
thud with no pain
iii. Gas from Ascities
1. Fluid wave test: fluid wave present with ascites; no change with gas
2. Shifting dullness: tympanic note over abdomen and dullness where there is fluid; then have person roll toward you shifting
the fluid and percuss for dullness over tympany
d. Palpate (Light and deep)
i. Liver: if palpated 1-2cm below right costal margin, it is enlarged; record number of cm and consistency (hard, nodular) and tenderness
ii. Spleen: not normally palpable (enlarged 2-3x normal size to be felt)—can rupture easily (don’t palpate)
1. Palpate obliquely with right hand on the LUQ with fingers pointing toward left axilla and just inferior to rib margin (push
deep and under left costal margin and ask person to take deep breath—should feel nothing firm)
2. Enlarged with Mono, trauma, leukemias, and lymphomas
iii. Kidneys: should feel nothing
iv. Aorta: palpate by pinching b/t thumb and finger (normally 2.5-4cm wide, left of midline, and pulsates anteriorly)
v. Rebound tenderness: Blumberg Sign—by pressing firmly and removing quickly, should elicit no pain with release of pressure
1. Pain=peritoneal inflammation (appendicitis)
vi. Inspiratory arrest: Murphy Sign—palpate under liver and ask pt to take a deep breath
1. Pain=inflammation of gallbladder (cholecystitis); pt will usually stop inspiring midway
Know changes with aging process within these systems
a.
On inspection, you may note increased deposits of subq fat on the abdomen and hips because it is redistributed away from the extremities
b. Abdominal musculature is thinner and has less tone than that of the younger adult
c.
Because of thinner, softer abdominal wall, organs may be easier to palpate
d. Liver is easier to palpate
e.
Normally you will feel the liver edge at or just below the costal margin
f.
Distended lungs and a depressed diaphragm – liver is palpated lower
g. Kidneys are easier to palpate
h. Changes in GI system:
i. Salivation decreases causing dry mouth and decreased sense of taste
ii. Esophageal emptying is delayed (supine feeding increases risk for aspiration)
iii. Gastric acid secretions decreases: may lead to pernicious anemia, iron deficiency anemia, and malabsorption of Ca
iv. Incidence of gallstones increases
v. Liver size decreases by 25% b/t ages 20 & 70; liver function remains normal; drug metabolism impaired (age 65—33% blood flow
decline)
vi. Constipation
Describe pulsations—normal and abnormal in abdomen. Where may these pulsations be seen or felt
a.
Under palpation above
What are vascular sounds (arterial and venous) in abdomen—and location (p. 562)
a.
Arterial: bruit indicates turbulent blood flow (found in constricted, abnormally dilated, or tortuous vessels)
i. Listen with bell
ii. Conditions:
1. Aortic aneurysm: murmur is harsh, systolic, or continuous and accentuated with systole (HTN)
2. Renal artery stenosis: murmur is midline or toward flank, soft, low to medium pitch
3. Partial occlusion of femoral arteries
b. Venous hum: rare; heard in periumbilical region
i. Originate from inferior vena cava; medium pitch, continuous sound, pressure on bell may obliterate it
ii. May have palpable thrill
iii. Occurs with portal HTN and cirrhotic liver
Differentiate light and deep palpation
a. Light palpation:
i. With the first four fingers close together, depress the skin about 1cm
ii. Make a gentle rotary motion, sliding the fingers and skin together
iii. Life the fingers (do not drag them) and move clockwise to the next location around the abdomen
iv. The objective is not to search for organs but to form an overall impression of the skin surface and superficial musculature
v. Save examination of any identified tender areas until last
vi. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the exam
b. Deep palpation:
i. Uses same technique as light palpation but push down about 5-8cm (2-3in)
ii. Moving clockwise, explore the entire abdomen
If a mass is noted—what are the eight assessment areas to be done to differentiate a normal palpable structure from enlarged organ (p. 547)
a.
Location
b. Size
c.
Shape
d. Consistency (soft, firm, hard)
e.
Surface (smooth, nodular)
f.
Mobility (including movement with respirations)
g. Pulsatility
h. Tenderness
Differentiate hyper/hypoactive bowel sounds—signs/symptoms and possible causation factors
a. Hyperactive: loud, high-pitched, rushing, tinkling sounds that signal increased motility
3.
3.
4.
5.
6.
7.
8.
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i.
ii.
9.
10.
11.
12.
13.
Loud, gurgling sounds, “borborygmi” signal increased motility
Occur with early mechanical bowel obstruction (high-pitched), gastroenteritis, brisk diarrhea, laxative use, and subsiding paralytic
ileus
b. Hypoactive: follow abdominal surgery or with inflammation of the peritoneum
i. Signals decreased motility
ii. Peritonitis
iii. Paralytic ileus as following abdominal surgery; late bowel obstruction; pneumonia
c.
Absent: no sounds in 5min in all four quads
Why does auscultation precede percussion and palpation
a.
Percussion and palpation can increase peristalsis—gives false interpretation of bowel sounds
Know sing/symptoms of the following conditions: costovertebral angel tenderness, hepatomegaly, splenomegaly, pleural friction rub, aortic
aneurysm, cirrhosis, gallbladder disease, peritoneal friction rub
a.
Peritoneal friction rub: rough, grating sound (two pieces of leather) indicates peritoneal inflammation; occurs over organs with a large surface
area in contact with peritoneum
i. Liver: friction rub over lower right rib cage, from abscess or metastatic tumor
ii. Spleen: friction rub over lower left rib cage in left anterior axillary line, from abscess, infection, or tumor
b. Costovertebral angel tenderness: sharp pain occurring with inflammation of the kidney or paranephric area
c.
Hepatomegaly:
i. Enlarged, smooth, and non-tender (fatty infiltration, portal obstruction or cirrhosis, high obstruction of IVC, and lymphocytic
leukemia)
ii. Enlarged, smooth and tender (early HF, acute hepatitis, or hepatic abscess)
iii. Enlarged nodular liver: occurs with late portal cirrhosis, metastatic cancer, or tertiary syphilis
d. Splenomegaly: enlarges down and to midline (not up d/t diaphragm); can extend down into left pelvis
i. Acute infections (mono): moderately enlarged, soft, with rounded edges
ii. Chronic causes: firm or hard, with sharp edges
iii. Usually not tender to palpation; tender if peritoneum is also inflamed
e.
Aortic aneurysm: located below renal arteries (>95%) and extends to umbilicus
i. Focal bulging >5cm; palpable ~80% of cases; feels like a pulsating mass in upper abd just to the left of midline; bruit heard; femoral
pulses heard but decreased
f.
Gallbladder disease: felt behind liver border as a smooth and firm mass (like a sausage)
i. Acute cholecystitis
ii. Painful to fist percussion and Murphy Sign present (inspiratory arrest)
iii. Nontender, enlarged gallbladder also feels like smooth sausage-like mass (occurs with stones—common bile duct obstruction)
Differentiate solid and hollow viscera—and organ examples
a.
Solid: those that maintain a characteristic shape
i. Liver, pancreas, spleen, adrenal glands, kidneys, ovaries, and uterus
b. Hollow: stomach, gallbladder, SI, colon, and bladder (depends on contents of each)
Know 4 quadrants of abdomen—anatomy in each quadrant
a.
RLQ:
i. Cecum, appendix, right ovary and tube, right ureter, right spermatic cord
b. RUQ:
i. Liver, gallbladder, duodenum, head of pancreas, right kidney and adrenal gland, hepatic flexure, part of ascending and transverse
colon
c.
LUQ:
i. Stomach, spleen, left lobe of liver, body of pancreas, left kidney and adrenal gland, splenic flexure, part of transverse and descending
colon
d. LLQ:
i. Part of descending colon, sigmoid colon, left ovary and tube, left ureter, left spermatic cord
e.
Midline:
i. Aorta, uterus (if enlarged), bladder (if distended)
Identify common cause of abdominal distention
a.
Obesity:
i. Inspection: uniformly rounded; umbilicus sunken (adheres to peritoneum, and layers of fat are superficial to it)
ii. Auscultation: Normal bowel sounds
iii. Percussion: Tympany; scattered dullness over adipose tissue
iv. Palpation: Normal; may be hard to feel through thick abdominal wall
b. Air or gas:
i. Inspection: single round curve
ii. Auscultation: Depends on cause of gas (decreased or absent bowel sounds with ileus; hyperactive with early intestinal obstruction)
iii. Percussion: Tympany over large areas
iv. Palpation: May have muscle spasm of abdominal wall
c.
Ascites:
i. Inspection: Single curve; everted umbilicus; bulging flanks when supine; taut, glistening skin; recent weight gain; increase in abd
girth
ii. Auscultation: Normal bowel sounds over intestines; diminished over ascitic fluid
iii. Percussion: Tympany at top where intestines float; dull over fluid; produces fluid wave and shifting dullness
iv. Palpation: taut skin and increased intra-abd pressure limit palpation
d. Ovarian cyst (large):
i. Inspection: curve in lower half of abd; midline; everted umbilicus
ii. Auscultation: normal bowel sounds over upper abd where intestines pushed superiorly
iii. Percussion: top dull over fluid; intestines pushed superiorly; large cyst produces fluid wave and shifting dullness
iv. Palpation: transmits aortic pulsations, whereas ascites does not
e.
Pregnancy:
i. Inspection: Single curve; umbilicus protruding; breasts engorged
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ii. Auscultation: fetal heart tones; bowel sounds diminished
iii. Percussion: tympany over intestines, dull over enlarged uterus
iv. Palpation: fetal parts; fetal movement
f.
Feces:
i. Inspection: localized distention
ii. Auscultation: normal bowel sounds
iii. Percussion: tympany predominates; scattered dullness over fecal mass
iv. Palpation: plastic-like or rope-like mass with feces in intestines
g. Tumor:
i. Inspection: localized distention
ii. Auscultation: normal bowel sounds
iii. Percussion: dull over massif reaches up to skin surface
iv. Palpation: defined borders; distinguish from enlarged organs or normally palpable structure
14. Differentiate: incisional hernia, epigastric hernia and umbilical hernia
a.
Umbilical: soft, skin-covered mass (protrusion of the omentum or intestine through a weakness or incomplete closure in the umbilical ring)
i. Accentuated with increased intra-abd pressure (crying, coughing, vomiting, or straining)
ii. Adults: pregnancy, chronic ascites, or with chronic intrathoracic pressure (asthma, chronic bronchitis)
b. Incisional: bulge new an old operative scar that may not show when a person is supine but is apparent when the person increases intra-abd
pressure by a sit-up, standing, or by the Valsalva maneuver
c.
Epigastric: small, fatty nodule at the epigastrium in midline, through the linea alba (usually palpable when standing, not seen)
18