The ability to perform and document patient assessment procedures is vital to the practice of medicine - a complete and accurate assessment is the starting point to providing thorough patient care. This course is intended as a review of the processes and techniques associated with patient assessment. This course takes you step-by-step through each assessment procedure including techniques for effectively communicating the assessment process and findings to patients.

Progress in the science and technologies relating to patient assessment has placed increasing demands on non-physician health care professionals (from RNs and LVNs to Respiratory Care Practitioners). The integration of assessment with treatment is a necessary outcome of the growing complexity of the roles and functions being assumed by these non-physician caregivers.

It is no longer acceptable to initiate or alter therapy or treatments without careful consideration of the underlying disorder and its clinical manifestations. Since it is not possible for physicians to be experts in all the fields in which their allied health companions practice, decisions regarding when to begin, change, or end treatments or therapies must be based on tangible clinical evidence, with input from all caregivers.

Although the physician has primary responsibility for these decisions (not unlike the “captain of the ship” concept), it is essential for other caregivers to participate in the clinical decision-making process. In order to fulfill this role effectively, nurses and RCPs must assume responsibility for gathering and interpreting relevant patient data.

These non-physician caregivers have historically had the option of communicating with attending physicians regarding the patient’s prescribed therapeutic regimen. Lack of confidence and sometimes even fear of having their input rejected (and possibly disrespected) has inclined many caregivers to remain silent. This has resulted in the prescription and performance of numerous costly and unnecessary procedures (especially in the area of patient’s respiratory care).

Author’s Note:
In this course, the terms nurses, RCPs, and caregivers are used interchangeably because all the terms refer to non-physician health care professionals who are trusted licensed professionals and whose sole purpose is to provide health care. In addition, there are a wide variety of examinations and techniques included. While some of you may not be concerned with or ever perform all of these, we have tried to make the information here as comprehensive as is possible in a review course. It is our hope that even after you are finished taking the course, you will find this a useful reference tool to keep on hand.

In recent years, however, the nation-wide heightened focus on controlling health care costs, and the increasingly sophisticated training received by caregivers have led to considerably expanded roles, especially in the delivery of health care services. Nursing was among the first of various specialty groups to take on more patient assessment responsibilities. With the advent and proliferation of therapist-driven protocols, physicians have come to depend on both nurses and respiratory care practitioners for identifying appropriate respiratory care and evaluating the effects the therapy is having on the patient.

In recognition of this expanded role for non-physician caregivers, even the new matrix for the national exam for respiratory therapists indicates that caregivers should be able to "determine the appropriateness of the prescribed respiratory care plan and recommend modifications where indicated...(caregivers should be able to) analyze available data to determine pathophysiologic state (of patients), review planned therapies, establish therapeutic goals, determine appropriateness of prescribed therapies and goals...(and) recommend changes in therapeutic plans if indicated, based on (patient) data."

"Patient data" and how to interpret it is the focus of this course. Nurses have their practice guidelines to follow regarding assessing the well-being of patients, and RCPs have their therapist-driven protocols which are based on respiratory practitioners being able to analyze available patient data to determine their pathophysiological state. This requires having excellent observational and clinical evaluation skills.

Upon successful completion of this course, and given an open-book, multiple-choice exam, you will be able to correctly answer a minimum of 90% of the test items requiring you to:

• List and explain the steps involved in conducting an initial physical assessment of the patient
• Identify the key elements of conducting patient interviews and taking and documenting a medical history
• Discuss the importance of radiographs, ECGs and various tests conducted in the patient assessment process
• Explain the role of “interpretation” of laboratory test data

The evaluation of patients calls for the application of all the skills of the trained professional. Some of the more important characteristics of the patient’s condition that may be detected by a careful and skilled observer include: the patient’s physical appearance, respiratory status, and even his/her apparent mental and emotional state.

Evaluation of those characteristics requires the caregiver to have in-depth knowledge of respiratory diseases and their symptoms. The caregivers must also be able to recognize the physical changes that occur in pulmonary patients, and be aware of the types of "complaints" those changes generate.

The health care professional must be aware of the wide variety of diagnostic tests available today, especially those relating to lung function, and must be able to ascertain and quantify abnormalities shown on test results. The caregiver is responsible for assessing patients for changes in respiratory status, for performing an overall physical assessment, and for interpreting available clinical data including the patient’s hemodynamics, chest x-rays, EKGs, and data from lab tests. In brief, caregivers must be proficient in gathering patient data, analyzing it, and providing a valid interpretation for other health care professionals.

Documentation

It is also important that health care professions know how to document their findings. One of the most commonly used formats used for documenting patient data is as follows:

• Record when the patient was evaluated, including: day, month, year, and time)
• Document the original diagnosis, and indicate when the symptoms first occurred (if available), and record any problems that are secondary to the primary diagnosis

While the format in which the information is recorded varies from institution to institution, it generally includes:

• Subjective assessment: based on the interview with the patient, including his own observations and descriptions of the complaint or symptoms.
• Objective data: based on the information obtained from x-rays, diagnostic exams, and notes from the physician and nurse
• Patient evaluation: record the results of the interview, visual assessment, percussion, auscultation, and palpation
• Document the original treatment plan, and document the clinical and therapeutic objectives of that plan
• Patient response: record how the patient responds to application of the therapy
• Document recommendations regarding continuance, modification, or discontinuance of the therapy; if applicable, record recommendations for additional tests and the results of communications with other members of the health care team
• Record the patient assessment in the procedures column of the patient’s Therapy Procedure Log
• Some of the most useful methods of gathering data regarding patients involve the interview, history-taking, and physical examination. While it is at best difficult to separate the three since they often all occur simultaneously in the clinical setting, for the purposes of this module we will try to examine their important characteristics as separate entities.

The interview takes place at the very beginning of the relationship with patients. The practitioner simply proceeds to ask the patient about the nature of his/her problem or complaint. This patient interview can reveal important information relating to symptoms, the patient’s emotional/mental state, and his/her own perception of the problem. The interview is when questions regarding complaints of cough and dyspnea are clarified. Signs of distress during the interview include: the patient sitting forward or in a braced position, anxious or fearful facial expressions, rapid respiratory rates, and interrupted speech patterns.

The purposes of the initial patient interview are to establish rapport, identify the functional status of patient, elicit assessment data, and introduce therapy. You’ve probably heard it said that "how" you say something is often as important as "what" you say. In that vein, before we discuss the types of questions you should ask during the initial patient interview, let’s review interviewing techniques and how to structure the interview.

A basic but important aspect of interviewing involves the caregiver being able to convey genuine concern for the patient’s well-being. Empathy towards the patient can be expressed in several ways. For example, establishing good eye contact during the interview not only lets patients know you are interested in what they are saying, but helps the health care professional control the interview.

Patients can easily sense when a practitioner is doing the minimum, or just "doing his job" and has no sincere interest in their problems. Clinicians who have this approach not only turn off the patient, but also frequently overlook potentially significant information. As a result, their assessment of the patient is incomplete, inaccurate, and often leads to the prescription of inappropriate or unnecessary treatments.

Another way caregivers can convey their genuine concern for the patients’ condition involves how they ask questions during the interview. Posing questions that can be answered with a simple "yes" or "no" is usually inappropriate, counter-productive, and fails to encourage productive communication. An interview that employs more open-ended questions calling for extended responses encourages the patient to "open-up", and reveals information that facilitates an accurate patient assessment. When appropriate, the use of touch may also be an effective means of demonstrating empathy during an interview.

Structuring the Interview

In order to increase the chances of a successful outcome for the interview, even the briefest of patient assessment interviews needs to have a pre-established structure. The nature and content of the questions that will be asked during the interview require an environment that is private and quiet in order to encourage honest and effective communications.

Prior to entering a patient’s room, you should prepare your thoughts so that you’re ready to ask appropriate questions that will enable you to obtain pertinent clinical information. If you’re well organized, you’ll be able to avoid repeating questions and won’t forget to ask key questions. Whenever possible, the setting for the interview should allow for a face-to-face conversation. You should begin the interview by addressing the patient by name, introducing yourself, and explaining your role and the purpose of the interview. This should start the process of putting the patient at ease regarding what is going on.

Observing the patient closely and listening closely during the interview is crucial to your ability to identify his/her mood, level of intelligence, and general state of well-being. Acutely ill or apparently anxious patients may need some reassurances prior to starting in-depth questioning.

Interview Techniques

As an experienced professional accustomed to conducting patient interviews, you probably have adopted a series of questions that you have found works well. This discussion is meant as a review, and may be helpful if you’ve possibly gotten into a rut in your questioning routine. There are several types of questions you can employ to assess patients. A brief review of the types of questions is helpful since each has its place in certain situations.

The most common questions are called direct questions. These are ones that patients can answer with a simple yes or no, or with specific, brief information. Direct questions are most useful in short interviews to assess the patient’s progress toward therapeutic goals. These questions keep the patient focused on relevant topics and help shorten the conversation. It is possible however, to overuse direct questions, causing patients to feel overwhelmed and giving them the sense that you are rushed and aren’t really concerned about their condition.

It is important to word direct questions carefully since most patients tend to answer yes if they think that’s the answer you want to hear. For example, if you ask patients whether their breathing has improved today, they may automatically answer "yes" because they think that is the answer you want to hear. A better way to phrase the question may be to ask, "Are you feeling any better today?" If the patient’s answer is yes, you can counter by asking, "In what way do you feel better today?" This gives the patient an opening for more detailed information without feeling any pressure from you.

It is up to you to not only to ask the right questions in a proper manner, but also to recognize the significance of the patient’s responses to your questions. That is what makes open-ended questions more useful than direct questions. Open-ended questions tend to encourage patients to be more open and talkative about their health concerns they are particularly useful for the initial interview to identify the various symptoms and details pertaining to their complaints.

Questions like "Under what conditions do you feel a shortness of breath?" tend to encourage patients to offer more information than do direct (and somewhat limiting) questions like "Do you ever feel shortness of breath?" Open-ended questions, however, may not result in identifying all the important details since this type of questioning does not direct the patient. The most effective and productive interview contains a combination of direct and open-ended questions.

Interview Topics

Many of the questions posed during the initial interview pertain to the patient’s medical history, including:

• Demographic information, including: patient’s name, date of birth, nationality, occupation, marital status, religious affiliation, and referral source.
• Patient’s answers and brief self-descriptions of physical condition to questions posed during the interview, including:
• Chief complaint: What made the patient decide to seek medical assistance? -- In his own words, and your comments.
• Present illness: Record the patient’s and your description of current symptoms, when they first occurred and whether they have gotten worse or better with time. Be sure to include a description of the location, frequency and duration of occurrence, severity of pain, and identification of the factors that contribute to an increase or diminution of the symptoms.

Caregivers should take special note of problems involve patient’s cardiopulmonary system, asking him about the following:

• Cough: Does the patient have a cough? If so, so does he/she describe it as severe, moderate, or slight? If you observe the cough, record your evaluation. Ask patients how long they’ve had the cough, when is it the worst, the least. Document the cough’s characteristics: hacking, dry, productive of mucus or phlegm, etc. If they cough up blood, determine the exact amount, color, and consistency of the blood.
• If the patient has Hemoptysis (expectoration or coughing up of blood or bloody sputum from the lungs), this can be significant in the diagnosis; however, you need to be aware not to confuse Hematemesis (vomiting of blood) with hemoptysis.
• Dyspnea: Does the patient ever feel short of breath, during rest or physical activity? Ask him to describe the degree of shortness of breath on an imaginary scale of one to ten.

Dyspnea is the subjective sensation of a shortness of breath. The person with dyspnea consciously experiences symptoms of difficult, labored, and uncomfortable breathing in conditions other than heavy exercise. The experience of dyspnea is subjective and is influenced by the patient's reactions and emotional state at the time. Only the patient can determine its severity.

Dyspnea can be either acute or chronic and can be associated with a vast array of diseases such as respiratory, cardiac, endocrine, renal, neurologic, metabolic, hematologic, and even psychologic disturbances. Treatment must be directed to discovering and treating the underlying cause.

If the dyspneic episode is acute then every action must be taken to secure the patient's airway and provide oxygenation and ventilation. Causes of acute dyspnea may include airway obstruction, pneumothorax, pulmonary embolus, pulmonary edema, pneumonia, asthmatic attack, pulmonary hemorrhage, or even anxiety. In acute cases of dyspnea, the problem will go away when the underlying cause is resolved.

In chronic lung disease such as COPD and various fibrotic lung diseases the dyspnea may never go away. In these cases, the treatment of the underlying process will not always alleviate the symptoms of dyspnea. Causes for chronic dyspnea may include airway disease, lung parenchymal disease, pulmonary vascular disease, pleural process, chest wall abnormality, anemia, deconditioning, cardiac disease, thyroid disease, or neuromuscular disorders.

Clinical assessment of the patient should be made from a thorough physical assessment along with a patient history. Using muscles of respiration is an obvious indication of dyspnea along with tachycardia, diaphoresis, and tachypnea. A bilateral paradoxical breathing pattern is often a sign of possible respiratory failure. Auscultation of the airways will also be important to reveal constricted airways and consolidation as a cause for the dyspnea.

Important questions to ask the patient should include: when the dyspnea started, whether the onset was gradual or abrupt, where the patient was, what the patient was doing at the time, severity of the symptoms, any possible precipitating factors, any changes in the patient's health status, coughing and sputum production, and any associated symptoms such as chest pain, change in consciousness, etc.

A pulse oxygen saturation reading is a good beginning measurement along with routine vital signs. This can then be followed up with more detailed laboratory tests such as arterial blood gases, blood analysis, and an EKG among other things.

Episodes of dyspnea can easily lead to feelings of anxiety and panic, which then creates more shortness of breath. When the patient feels that he cannot get enough air anxiety increases, which increases respiratory rate and oxygen demands. This vicious cycle worsens the dyspnea.

Techniques to break the cycle of dyspnea will include providing reassurance that something is being done to provide relief, instructing the patient to use purse-lip breathing techniques to gain control of his breathing, maintaining the patient in a Fowler's position to allow maximum lung expansion, encouraging relaxation techniques, along with providing medication and oxygen therapy.

American Thoracic Society Grade of Breathlessness Scale

• Wheezing: This involves emission of a whistling-like sound resulting from narrowing of the lumen of a respiratory passageway. Ask and observe if the patient is wheezing. If so, inquire as to when it appears to occur most and what seems to provoke it.
• Chest Pain: Do they experience it? If so, ask where it’s located, is the onset sudden, does breathing deeply breathing or coughing aggravate it?
• Locomotor System: Does the patient ever experience pain when using his muscles or moving his joints? Is he currently experiencing such pain?
• Nervous System: Ask the patients if they are currently experiencing any headaches, muscle weakness, dizzy feelings, faintness, seizures or convulsions, tremors, vertigo, diplopia, paralysis, paresis, or ataxia.
• Psychiatric Problems: Ask if they are currently feeling particularly nervous, stressed, having episodes of depression, having trouble sleeping or nightmares, or suffering any memory loss.
• Anorexia and Weight Loss: Ask if the patient has recently experienced a loss of appetite, with an attendant loss of weight. This can be very relevant to making a proper diagnosis of respiratory problems.
• Night Sweats: Ask if the patient is experiencing excessive perspiration during sleep at night. If so, ask specific questions regarding the location and characteristics of the perspiration, including odor.
• Digestive System: Ask if the patients are having trouble digesting their meals. Are they experiencing nausea, or vomiting? Does their digestive system involve excess gas or belching, excessive stomach sounds? Do they have difficulty swallowing, and do they experience dark or bloody stools?
• Genitourinary System: Ask if the patients are experiencing any pain or difficulty urinating, are incontinent, have any renal stones, or urinary infections.
• Endocrine System: Ask if the patient is diabetic, has intolerance to heat or cold, or has recently experienced any change of voice.

General Considerations

Remember that there are two halves to each interview, patient-centered and caregiver-centered.

Opening the Interview

It is important to begin each medical interview with a patient-centered approach.

1. Set the Stage

• Welcome the patient - ensure comfort and privacy
• Know and use the patient's name - introduce and identify yourself

2. Set the Agenda

• Use open-ended questions initially
• Negotiate a list of all issues - avoid detail!
      Chief complaint(s) and other concerns
      Specific requests (i.e. medication refills)
• Clarify the patient's expectations for this visit - ask the patient "Why now?"

3. Elicit the Patient's Story

• Return to open-ended questions directed at the major problem(s)
• Encourage with silence, nonverbal cues, and verbal cues
• Focus by paraphrasing and summarizing

4. Make the Transition

• Summarize the interview up to that point
• Verbalize your intention to make a transition to the physician-centered interview

History of Present Illness

Primary History

You should always begin the caregiver-centered phase of the interview with "WH" questions (where? what? when?) directed at the chief complaint(s). Build on the information the patient has already given you. Flesh out areas of the story you don't fully understand. Try to quantify whenever possible (pain on a scale of 1 to 10, number of days instead of "a while," etc.). Be as specific as possible and try to record what the patient says accurately, without interpretation. Address as many of these details as appropriate:

1. Location
2. Radiation
3. Quality
4. Quantity
5. Duration
6. Frequency
7. Aggravating Factors
8. Relieving Factors
9. Associated Symptoms
10. Effect on Function

Secondary History

The secondary history expands on the primary history, especially any associated symptoms. It is useful to think of the secondary history as a focused review of systems (see below). These questions often bring out information that supports a certain diagnosis or helps you gauge the severity of the disorder. Unlike the primary history, a certain amount of interpretation (and experience) is necessary. Here are some examples:

Headache
Ask about nausea and vomiting.
Ask about visual changes.
Ask about the relationship with stress, work, weekends, and emotions.

Ear Problems
Ask about hearing loss or ringing in the ears.
Ask about dizziness or vertigo.

Tertiary History

The tertiary history brings in elements of the past medical history (see below) that have direct bearing on the patient's condition. By the time you get to the tertiary history you may already have a good idea of what might be going on. (This will be fine-tuned by the physical exam.) Here are some examples:

Any HEENT or Chest Disorder
Does the patient smoke? How much? How long?
For children, does someone smoke in the home?

Breast Problems
Is there a family history of breast cancer?

Abdominal Pain
Does the patient smoke? How much? How long?
How much alcohol does the patient consume?
Prior surgery? Has the appendix been removed?

Chest Pain
Does the patient smoke? How much? How long?
Did the patient's parents die of a heart attack? At what ages?

Review of Systems

The review of systems is just that, a series of questions grouped by organ system including:

1. General/Constitutional
2. Skin/Breast
3. Eyes/Ears/Nose/Mouth/Throat
4. Cardiovascular
5. Respiratory
6. Gastrointestinal
7. Genitourinary
8. Musculoskeletal
9. Neurologic/Psychiatric
10. Allergic/Immunologic/Lymphatic/Endocrine

Past Medical History

The past medical history is essentially background information related to the patient's health and well being. A brief past medical (and social) history often includes these elements:

1. Allergies and Reactions to Drugs (What happened?)
2. Current Medications (Including "Over-the-Counter")
3. Medical/Psychiatric Illnesses (Diabetes, Hypertension, Depression, etc.)
4. Surgeries/Injuries/Hospitalizations (Appendectomy, Car Accident, etc.)
5. Immunizations
6. Tobacco/Alcohol/Drug Use
7. Reproductive Status for Females
   Last Menstrual Period
   Last Pelvic Exam/Pap Smear
   Pregnancies/Births/Contraception
8. Birth History/Developmental Milestones for Children
9. Marital/Family Status
10. Occupation/Exposures

For more on Past Medical History, be sure to ask the patient for information regarding:

• Past Illnesses, including: recurrent episodes of pulmonary infections, infectious diseases, infantile eczema, atopic dermatitis, accidents, allergic rhinitis, or co-existing conditions such as diabetes, hypertension, thyroid, or other glandular disorders should be noted. Other illnesses to inquire about: rheumatic fever, diabetes, pneumonia, tuberculosis, arthritis, jaundice, kidney or heart trouble, ulcer, phlebitis, anemia, asthma, hay fever, hives, cancer, measles, adenoviral infections, or pertussis in childhood which may predispose the individual to bronchiectasis. Is the patient taking any medications, such as: antihypertensives, steroids, bronchodilators, heart medications, or diuretics.
• Past Hospitalizations: you also need to document any past hospitalizations for infection or surgery (especially chest procedures which may be the cause of cardiorespiratory insufficiency). Also inquire about dental extractions, upper respiratory tract surgery, or aspiration of foreign bodies, because they may cause pulmonary abscesses.
• Allergies: finally you should ask patients if they have any allergies, for example: to animals, flowers, perfumes, dust, drugs and foods which may trigger allergic reactions.

Family History: You should inquire about the patient’s familial disease history (particularly hereditary diseases, such as cystic fibrosis and asthma), and illnesses such as TB. You should also determine the patient’s marital status, and the health status of a spouse.

Social and Environmental History: Is the information regarding the patient’s background and living habits that may be associated with the development of illness. Areas where the patient has worked, lived, or traveled should be listed, with the amount of time spent in each area. In addition, your interview should cover the following:

• Patient’s level of education and general economic circumstances
• Military service experience
• Occupational history: Should include the duration of each job. It is important to note exposure to coal dust, asbestos, cloth or wood fibers, or toxic gases. Also, be sure to inquire as the level of stress they feel on the job.
• Activities: Social, religious, hobbies and habits. Do they engage in any hazardous activities? Ask them to describe their general diet, sleeping patterns. Are they having any problems with insomnia? Is adding pillows for sleeping or sleeping in a recliner common? Do they exercise, use tobacco, alcohol, coffee, special drugs (laxatives, sedatives, psychotropics)?

Observation of the patient, which is the initial phase of the physical examination, actually begins during the interview and needs to be conducted meticulously. Be aware that there will inevitably be some overlap of the information gleaned during the interview, observation, and subsequent hands-on physical examination. All three yield valuable information.

The observation should begin with the caregiver’s glance around the patient’s room that often can tell you a lot about the clinical situation. Some of the more revealing items to look for include the presence of isolation signs and supplies, various monitors or equipment, or chest tubes.

The caregiver should observe the rate, rhythm and frequency of the patient’s respiration during exercise and at rest. It is also important to observe the shape of the patient’s chest, and take note of whether or not the patient needs to use accessory muscles of respiration. Abnormalities in the formations of the bony thorax and spine (such as kyphosis, pectus excavatum, scoliosis, or lordosis) should also be noted.

It is important to take note the patient’s bed. For example, if the bed is in the Trendelenburg position, it can be suggestive of the existence of hypotension. A bed locked in an upright position or one that has an unusual number of pillows can suggest orthopnea resulting from CHF/pulmonary edema.

The patient’s position in the bed can also be revealing. For example, patients with severe lung disease tend to avoid lying flat in bed because they generally have difficulty breathing in that position.

Many patients who are experiencing excess work of breathing brace their upper torso by resting their arms on the bedside table or holding on to the side rails in order to get increased leverage for the accessory muscles of respiration. Air trapping in COPD patients flattens their diaphragm, so they can frequently be seen in this position because they rely on the upper chest muscles to facilitate breathing.

Observing for Abnormalities

Skin: Observation begins with the skin and mucus membrane color, which indicates oxygenation. If the lips or nail beds have orange, green, or yellow tints, the patient may have impaired liver function. Flushed skin indicates either a fever or high blood pressure. Anemic patients have very pale skin, and diaphoresis (sweating) can be caused by an increase in sympathetic discharge or increased work of breathing

The caregiver should also look for evidence of cyanosis. Cyanosis is a bluish tint of the skin and mucous membranes due to reduced hemoglobin in the subpapillary venous plexus. The amount of reduced hemoglobin depends on the hemoglobin concentration and oxygen saturation. This nonspecific symptom is related to either hypoxemia or decreased perfusion. Detecting cyanosis is often made difficult by available lighting and the patient’s normal skin color. Cyanosis becomes visible to most observers when the amount of reduced hemoglobin in the capillary blood exceed 5 to 6 g/dL. This may be due to a reduction in either arterial or venous oxygen content or both. When the arterial hemoglobin saturation drops to 75% or less, most observers see cyanosis in the mucous membranes of the lips and mouth, as well as the fingers.

Face, Head and Neck: See if the patient’s face is pale or flushed, scarred, swollen, or flabby. Patient distress (respiratory distress, cyanosis, or plethora) can be estimated from facial expressions. Head size, shape, contour, and symmetry are all important to take note of. Also see if there seems to be any tenderness over sinuses or mastoids. Observe any rigidity or limitation of motion in the patient’s neck. Note abnormal pulsation, scars, masses, enlarged salivary glands, or lymph nodes. Describe the thyroid gland, position of trachea, and note carotid and jugular pulses. Jugular venous distension is often due to congestive heart failure, and distention of the jugular veins during expiration can be due to severe obstructive lung disease.

• Ear, Nose, Mouth, and Throat: Check hearing acuity, noting any discharge from the ears, and briefly describe condition of ear drums. Note nasal airway obstructions, septal deviation, discharge, condition of mucosa, and polyps. Check breath odor, color and appearance of lips, tongue, gums condition of teeth, dentures, appearance of mucosa. Describe the palate, uvula, tonsils, and posterior pharynx when indicated, and record findings of examination of nasopharynx and larynx. Check for difficulty with a sore throat, hoarseness, speech defect, difficulty swallowing, or tonsillitis.
  
  
• Eyes: Respiratory distress can affect the patient’s pupils. Pupillary size can be affected by cerebral oxygenation, and indirectly by cardiac output.
  
  
• Hands and Ankles: Clubbing is a painless, uniform enlargement of the terminal segment of a finger or toe, and is indicative of dilating peripheral vessels and an increase in subcutaneous tissue as a compensatory mechanism for chronic, severe hypoxemia. In this condition a change in the angle between the nail and proximal skin to 180° or greater occurs. In the early stages it’s difficult to diagnose, but in its later stages diagnosis is relatively easy. The normal angle is 160° to 165° for fingers, and 175° for thumbs. Clubbing is said to be present if the hyponychial angle is increased more than 187° to 209°. Ankle edema is important to note because it indicates the possibility of venous return, peripheral vascular disease, fluid overload, and even heart disease.

Introduction

The patient interview and the caregiver's initial observations yield a great deal of valuable assessment information. The actual physical examination of the pulmonary patient, however, is most valuable to facilitate the caregiver's accurate evaluation of the patient’s condition and subsequent prescription of a treatment protocol.

Vital Signs

One of the most important aspects of the actual “hands-on” physical examination includes checking the patient’s vital signs.

The vital signs are a nonspecific but necessary part of any physical examination, and assessment of the vital signs is the most frequent evaluation technique performed in the clinical setting. The patient’s vital signs provide crucial information and clues regarding the patient’s overall health status, and his/her response to treatments.

Many times during a physical examination, the measuring of the vital signs gives initial evidence of an abnormality. The four basic vital signs are body temperature, pulse rate, blood pressure and respiratory rate. While an in-depth discussion of the vital signs is beyond the scope of this course, checking of vital signs should always be considered as part of a patient assessment.

Equipment Needed

• A Stethoscope
• A Blood Pressure Cuff
• A Watch Displaying Seconds
• A Thermometer

General Considerations

• The patient should not have had alcohol, tobacco, caffeine, or performed vigorous exercise within 30 minutes of the exam.
• Ideally the patient should be sitting with feet on the floor and his back supported. The examination room should be quiet and the patient comfortable.
• History of hypertension, slow or rapid pulse, and current medications should always be obtained.

Heartbeat

To begin the assessment of vital signs, the caregiver needs to be adept at taking the patient’s pulse. A pulse indicates a heartbeat and can be felt at any of the patient’s arteries. Documentation of the patient’s pulse should include the frequency, regularity, and quality of the heartbeat. Pulses monitored in adults include the radial, carotid, or femoral pulses. In children and infants, the brachial pulse is preferred. In the documentation process, it is important to note the rate per minute, as well as the regularity and quality of the pulse.

The amount of oxygen being delivered to the patient’s tissues is dependent on the heart’s ability to pump oxygenated blood through the circulatory system. The amount pumped per minute, cardiac output, is a direct function of heart rate and stroke volume. When the oxygen content of arteries dips below normal, often as a result of lung disease, the patient’s heart attempts to maintain normal oxygen delivery by increasing the cardiac output. This is achieved by increasing the heart rate.

The patient’s radial artery is most commonly used to assess the pulse rate. The number of times the heart beats per minute is measured by counting the pulse in the artery. The caregiver places the second and third finger pads on the radial pulse to count for about one minute. Be careful not to hold the patient’s wrist too far above the heart because that can make obtaining an accurate pulse difficult. The normal range for adult heart rates is between 60-100 beats per minute (bpm). The average adult pulse rate is 72/bpm.

A heart rate slower than 60/bpm is called bradycardia, while tachycardia is a rate greater than 100/bpm. A normal pulse beats in consistent intervals, and when the interval varies from beat to beat, the pulse is considered to be irregular.

The pulse rate is influenced by several factors, with exercise being the most obvious. With increased activity, the heartbeat increases 20-30 beats per minute to meet the body’s needs. It should return to normal within 3 minutes after the activity has ceased. The heart rate also increases in response to fear, anxiety, low blood pressure, anemia, fever, hypoxia, and some medications and for many other reasons. Heart rate decreases with hypothermia, certain arrhythmias, certain medications and other reasons.

Remember that spontaneous ventilation can influence pulse strength (amplitude) changes. A significant decrease in pulse amplitude during inhalation is known as pulsus paradoxus (paradoxical pulse). This is common in patients afflicted with obstructive pulmonary disease, particularly those experiencing an acute asthma attack. Pulsus paradoxus also signals the possible existence of mechanical restriction of the heart’s pumping action, such as is seen in constrictive pericarditis or cardiac tamponade. Taking a blood pressure measurement best assesses this condition. An alternating succession of strong and weak pulses, pulsus alternans, suggests left- sided heart failure and is not related to the presence of any respiratory diseases.

Evaluating the carotid, femoral, brachial, temporal, popliteal, posterior tibial, and dorsalis pedis can also assess the patient’s pulse. The carotid and femoral pulse should be used when the blood pressure is abnormally low. To find the carotid pulse, locate the larynx with the tips of your first two or three fingers, slide your fingers away from the larynx (Adam’s apple) toward the groove between the trachea and the large neck muscles, and feel for the pulse. Move your fingertips around until you find the strongest point and feel the pulse. Never use your thumb because it has a pulse of its own and could be mistaken for the patient’s pulse. Count the pulse rate and note whether it is strong, weak, regular or irregular.

If the carotid site is used, you should take care to avoid the carotid sinus area because it can evoke a strong parasympathetic response, causing bradycardia or asystole. To obtain a femoral pulse, visualize the crease between the leg and the abdomen, place the tips of your first two or three fingers at the midpoint, and feel for the pulse.

1. Sit or stand facing your patient.
2. Grasp the patient's wrist with your free (non-watch bearing) hand (patient's right with your right or patient's left with your left). There is no reason for the patient's arm to be in an awkward position, just imagine you're shaking hands.
3. Compress the radial artery with your index and middle fingers.
4. Note whether the pulse is regular or irregular:
   o Regular - evenly spaced beats, may vary slightly with respiration
   o Regularly Irregular - regular pattern overall with "skipped" beats
   o Irregularly Irregular - chaotic, no real pattern, very difficult to measure rate accurately
5. Count the pulse for 15 seconds and multiply by 4.
6. Count for a full minute if the pulse is irregular.
7. Record the rate and rhythm.

Interpretation

• A normal adult heart rate is between 60 and 100 beats per minute.

A pulse greater than 100 beats/minute is defined to be tachycardia. Pulse less than 60 beats/minute is defined to be bradycardia. Tachycardia and bradycardia are not necessarily abnormal. Athletes tend to be bradycardic at rest (superior conditioning). Tachycardia is a normal response to stress or exercise.

Blood Pressure

Blood pressure is an indication of how well the heart is pumping, how much blood it pumps, and how efficiently the job is performed. The pressure is the pressure of the blood against the walls of the blood vessels.

The force exerted on the walls of the arteries as blood pulses through them is called the arterial blood pressure. Arterial systolic blood pressure represents the peak force that is exerted during the contraction of the heart’s left ventricle. Diastolic pressure indicates the force that remains after relaxation. Pulse pressure is the variance between systolic and diastolic pressures. For example, if systolic pressure is 120 and diastolic pressure is 100, the pulse pressure is 20. Normal pulse pressure ranges between 35-40 mm Hg. When the pulse pressure measures less than 30 mm Hg, peripheral pulse is difficult to detect.

On the other hand, the patient’s blood pressure is determined by: the force of the left ventricular contraction, the systemic vascular resistance, and the blood volume. Normal systolic pressure ranges from 95-140 mm Hg, with an average of about 120 mm Hg. Normal diastolic pressure ranges from about 60-90 mm Hg, with the average norm being 80 mm Hg. Blood pressure is recorded as a fraction, by listing the systolic pressure over the diastolic pressure. For example, normal blood pressure is recorded as being 120/80 mm Hg.

Blood pressure rises or drops for a variety of reasons. Hypotension is defined as a drop in blood pressure to a measurement of less than 95/60 mm Hg. The most common causes of hypotension include: ventricular failure, peripheral vasodilatation, or low blood volume. Vital body organs receive inadequate blood flow in patients with hypotension. Inadequate circulation can impair O2 delivery to the tissues, causing tissue hypoxia to occur. As a result, it is important that prolonged hypotension be prevented.

When persons with normal blood pressure sit or stand up, blood pressure is relatively unaffected. However, similar actions may cause an abrupt drop in blood pressure among hypovolemic patients. This condition, which is referred to as postural hypotension, can be confirmed by measure the patient’s blood pressure in both the supine and sitting positions.

Sudden decreases in arterial blood pressure caused by postural hypotension can decrease cerebral blood flow, leading to syncope, or fainting. Treatment of postural hypotension involves administration of fluid or vasoactive drugs. It is important that untreated or unresponsive postural hypotension be considered when moving or ambulating a patient.

The systolic blood pressure generally decreases slightly with normal inhalation; however, a drop of more than 6-8 mm Hg during resting inhalation is abnormal and referred to as paradoxical pulse. Paradoxical pulse is caused by intrathoracic pressure swings created by the respiratory muscles during breathing. Negative intrathoracic pressure during inspiration assists venous return to the right ventricle (RV), however it impedes arterial outflow from the left ventricle (LV). Increased venous return increases RV pressures, thus restricting LV filling. This in turn reduces LV stroke volume and decreases systolic blood pressure during inhalation. Palpation may indicate the presence of paradoxical pulse, but it can only be quantified by auscultatory measurement.

Increases in patient blood pressure can have even more serious consequences. Blood pressure that consistently measures above 140/90 mm Hg is referred to as hypertension, which is usually caused by high systemic vascular resistance. A less common cause of hypertension is the increased force of ventricular contraction. Hypertension that is severe often results in congestive heart failure, central nervous system abnormalities, uremia, or cerebral hemorrhage leading to the patient suffering a stroke.

Measuring the patient’s blood pressure is most commonly accomplished the auscultatory method. This involves the use of a stethoscope and a sphygmomanometer. Be sure to check the stethoscope to be sure it’s in good working order prior to use. The sphygmomanometer measures arterial blood pressure, and consists of a manometer containing a scale for registering pressure as well as an inflatable bladder surrounded by a covering known as a cuff

Remember that cuffs come in various sizes, and that it is crucial that the proper-size cuff be used. Using the wrong-size cuff can cause erroneous blood pressure readings to be obtained. For example, if the cuff is too narrow for the patient’s upper arm, the reading obtained will be falsely high. A regular-sized cuff should be used if the arm’s circumference is less than 13 inches, arms with greater than a 13 inch circumference require use of a large-size cuff, and pediatric patients or adults with extremely small arms require use of a pediatric cuff.

When the caregiver applies the cuff to the patient’s upper arm and pressurizes it to exceed systolic blood pressure, brachial blood flow is stopped. As the cuff’s pressure is decreased slowly (at a rate of about 2-3 mm Hg per second) to the point just below systolic pressure, blood flow intermittently passes the obstruction. This partial obstruction of blood flow creates vibrations and turbulence called Korotkoff sounds, which can be heard by placing the stethoscope over the brachial artery distal to the obstruction.

At the point at which the first Korotkoff sounds are heard, systolic blood pressure is recorded. The point at which the sounds become muffled is the diastolic pressure, and this muffling is the final change in the Korotkoff sounds prior to their disappearance. If the muffling and cessation of the sounds occur at a wide interval, all three pressures should be recorded (120/80/60).

Besides using the wrong-sized cuff, other mistakes that cause erroneously high blood pressure measurements include:

• Cuff applied either too tightly or too loosely
• Excessive pressure placed in the cuff during measurement
• Inflation pressure held in the cuff
• Incomplete deflation of cuff between measurements

Extraneous room sounds, ventilators, static electricity, or the presence of an auscultatory gap may also cause errors in measurement of the patient’s blood pressure. The auscultatory gap consists of a 20-40 mm Hg drop with no sound between the first systolic sound and the continuous pulse sound. Inflating the cuff until the palpated radial pulse can no longer be felt can help prevent missing the opening snap. When the auscultatory gap is heard, both the opening snap pressure and pressure at which continuous pulses are heard should be recorded (160/140/80). Position the patient's arm so the antecubital fold is level with the heart. Support the patient's arm with your arm or a bedside table.

1. Center the bladder of the cuff over the brachial artery approximately 2 cm above the antecubital fold. Proper cuff size is essential to obtain an accurate reading. Be sure the index line falls between the size marks when you apply the cuff. Position the patient's arm so it is slightly flexed at the elbow.
2. Palpate the radial pulse and inflate the cuff until the pulse disappears. This is a rough estimate of the systolic pressure.
3. Place the stethoscope over the brachial artery.
4. Inflate the cuff to 30 mmHg above the estimated systolic pressure.
5. Release the pressure slowly, no greater than 5 mmHg per second.
6. The level at which you consistently hear beats is the systolic pressure.
7. Continue to lower the pressure until the sounds muffle and disappear. This is the diastolic pressure.
8. Record the blood pressure as systolic over diastolic ("120/70" for example).

Interpretation

• Higher blood pressures are normal during exertion or other stress. Systolic blood pressures below 80 may be a sign of serious illness or shock.
• Blood pressure should be taken in both arms on the first encounter. If there is more than 10 mmHg difference between the two arms, use the arm with the higher reading for subsequent measurements.
• It is frequently helpful to retake the blood pressure near the end of the visit. Earlier pressures may be higher due to the "white coat" effect.
• Always recheck "unexpected" blood pressures yourself.

In children, pulse and blood pressure vary with the age.
The following table should serve as a rough guide:

Notes

1. For more information refer to A Guide to Physical Examination and History Taking, Seventh Edition by Barbara Bates, published by Lippincott in 1999.
2. Unlike pulse, respirations are very much under voluntary control. If you tell patients you are counting their breaths, they may change their breathing pattern. You cannot tell someone to "breathe normally," normal breathing is involuntary.
3. With an irregular pulse, the beats counted in any 15-second period may not represent the overall rate. The longer you measure, the more these variations are averaged out.
4. Do not rely on pressures obtained using a cuff that is too small or too large. This is frequently a problem with obese or muscular adults where the regular cuff is too small. The pressure recorded will most often be 10, 20, even 50 mmHg too high! Finding a large cuff may be inconvenient, but you will also "cure" a lot of high blood pressure.
5. Maximum Cuff Pressure - When the baseline blood pressure is already known or hypertension is not suspected, it is acceptable in adults to inflate the cuff to 200 mmHg and go directly to auscultating the blood pressure. Be aware that there could be an auscultory gap (a silent interval between the true systolic and diastolic pressures).
6. Bell or Diaphragm? - Even though the Korotkoff sounds are low frequency and should be heard better with the bell, it is often difficult to apply the bell properly in the antecubital fold. For this reason, it is common practice to use the diaphragm when taking blood pressure.
7. Systolic Pressure - In situations where auscultation is not possible, you can determine systolic blood pressure by palpation alone. Deflate the cuff until you feel the radial or brachial pulse return. The pressure by auscultation would be approximately 10 mmHg higher. Record the pressure indicating it was taken by palpation (60/palp).
8. Diastolic Pressure - If there is more than 10 mmHg difference between the muffling and the disappearance of the sounds, record all three numbers (120/80/45).

Temperature

The temperature of the body indicates the amount of heat produced by the activity of changing food into energy. The body loses heat through perspiration, breathing, and the elimination of body wastes. The balance between heat production and heat loss determines the body’s temperature. The average normal body temperature is 98.6° F, with daily variances of about 1° F.

There are a variety of factors, including exercise and infections that can cause body temperature to increase. When temperature increases, CO2 production and, O2 consumption also increase. For example, with every 1° rise in temperature CO2 production and O2 consumption increase by nearly 10%. In turn, breathing frequency needs to increase in order to adequately compensate. Logically, declines in temperature produce just the opposite effect. A mild infection may cause the temperature to rise to 102° F, while a temperature over 106° F can be fatal.

Temperatures below normal are called hypothermia. Collapse will occur at 96.0° F, and death normally occurs if temperature goes below 93.0° for any length of time. The most common cause of hypothermia is extensive and prolonged exposure to cold temperatures in the environment. Hypothermia can also be caused by severe head injuries involving damage to the hypothalamus, an important regulatory agent for body temperature. As the body temperature falls to low levels, the hypothalamus initiates shivering to generate heat, and vasoconstriction to conserve heat. Patients with hypothermia may exhibit slow and shallow breathing and reduced pulse rates. Mechanical ventilators in the control mode may need to be significantly adjusted in the rate and depth of tidal volumes delivered as the patient’s temperature rises and falls below normal.

The body’s temperature is kept normal by balancing heat production with loss of heat. If the body did not discharge heat generated by metabolism, the temperature would rise about 2° F per hour. Peripheral vasodilatation, sweating, and respiratory ventilation help dissipate body heat.

Temperature can be measured is several different ways:

• Oral with a glass, paper, or electronic thermometer (normal 98.6F/37C)
• Axillary with a glass or electronic thermometer (normal 97.6F/36.3C)
• Rectal or "core" with a glass or electronic thermometer (normal 99.6F/37.7C)
• Aural (the ear) with an electronic thermometer (normal 99.6F/37.7C)

Of these, axillary is the least and rectal is the most accurate.

The patient’s body temperature is most commonly measured by using a glass or electronic thermometer at the site of the mouth, axilla, or rectum. The temperature measured at the rectal site most closely approximates the actual core temperature of the patient’s body. The most acceptable site for measuring adult temperatures is the mouth. If patients have been smoking or ingesting hot or cold liquid, taking of the temperature should be delayed for about 15 minutes to avoid inaccurate measurements

Oral temperatures should not be taken on patients breathing heated or cooled aerosol via facemasks because there is a tendency for erroneous measurements. However, oral temperatures are unaffected by simple oxygen administration via nasal cannula or mask. It is not necessary to remove the oxygen or use the rectal site on patients receiving simple oxygen therapy.

Respiration

Normal breathing frequency of an adult is 12-20 breaths per minute. The respiratory rate is counted by watching the patient’s abdomen or chest wall move in and out during respiration. The practiced caregiver should be able to easily identify even the subtlest breathing movements of patients at rest. It may be necessary in some cases to place a hand on the patient’s abdomen to confirm the breathing rate. In any event, caregivers should avoid letting the patient become aware that their breathing rate is being counted. One way to accomplish this is to count the respiratory rate after evaluating the pulse, keeping the fingers on the artery.

Exercise, fever, hypoxia, anxiety, pain, metabolic acidosis, and an increase in the work of breathing can increase frequency (e.g.: pulmonary fibrosis). Frequency decreases from head trauma, hypothermia, and ventilatory depressing medications.

Breathing patterns and effort should also be observed. Any respiratory abnormalities that increase the work of breathing usually cause the accessory muscles of ventilation to become active, even at rest. A significant reduction in lung volume, as that seen in atelectasis, usually results in rapid, shallow breathing. The greater the loss of lung volume, the higher the patient’s respiratory rate.

Common types of abnormalities seen in patients’ rate and rhythm of breathing include:

• Tachypnea: Breathing that is faster than normal and usually more shallow.
• Bradypnea: An abnormally slow rate of respiration
• Hyperpnea: Deep breathing
• Hyperventilation: Ventilation in excess of that necessary to meet metabolic needs
• Cheyne-Stokes Respirations: An abnormal breathing pattern characterized by alternating periods of apnea and periods of rising, then falling tidal volumes
• Kussmaul’s Breathing: Deep gasping type of respiration associated with severe diabetic acidosis and coma
• Obstructive Breathing: In obstructive lung disease, expiration is prolonged because of increased airway resistance. If the patient must increase his respiratory rate, he lacks sufficient time for full expiration. His chest over expands (air trapping) and his breathing becomes shallower.
• Biots’ Breathing: Characterized by several short breaths followed by long irregular periods of apnea
• Best done immediately after taking the patient's pulse. Do not announce that you are measuring respirations.
  1. Without letting go of the patients wrist begin to observe the patient's breathing. Is it normal or labored?
  2. Count breaths for 15 seconds and multiply this number by 4 to yield the breaths per minute.

In adults, normal resting respiratory rate is between 14-20 breaths/minute. Rapid respiration is called tachypnea

While there is some overlap between the following sections on examining the back and extremities and the material in the chest examination section, both are important aspects of the patient assessment process:

Examination of the Extremities and Back

Equipment Needed

• None

General Considerations

• The patient should be undressed and gowned as needed for this examination.
• Some portions of the examination may not be appropriate depending on the clinical situation (performing range of motion on a fractured leg for example).
• The musculoskeletal exam is all about anatomy. Think of the underlying anatomy as you obtain the history and examine the patient.
• When taking a history for an acute problem always inquire about the mechanism of injury, loss of function, onset of swelling (< 24 hours), and initial treatment.
• When taking a history for a chronic problem always inquire about past injuries, past treatments, effect on function, and current symptoms.
• The cardinal signs of musculoskeletal disease are pain, redness (erythema), swelling, increased warmth, deformity, and loss of function
• Always begin with inspection, palpation and range of motion, regardless of the region you are examining. Specialized tests are often omitted unless a specific abnormality is suspected. A complete evaluation will include a focused neurologic exam of the effected area.

Regional Considerations

· Remember that the clavicle is part of the shoulder. Be sure to include it in your examination.
· The patella is much easier to examine if the leg is extended and relaxed.
· Be sure to palpate over the spinous process of each vertebrae.
· It is always helpful to observe the patient standing and walking.
· Always consider referred pain, from the neck or chest to the shoulder, from the back or pelvis to the hip, and from the hip to the knee.
· Pain with, or limitation of, rotation is often the first sign of hip disease.
· Diagnostic hints based on location of pain

Inspection

1. Look for scars, rashes, or other lesions.
2. Look for asymmetry, deformity, or atrophy.
3. Always compare with the other side.

Palpation

1. Examine each major joint and muscle group in turn.
2. Identify any areas of tenderness.
3. Identify any areas of deformity.

Range of Motion

Start by asking the patient to move through an active range of motion (joints moved by patient). Proceed to passive range of motion (joints moved by examiner) if active range of motion is abnormal.

Active

1. Ask the patient to move each joint through a full range of motion.
2. Note the degree and type (pain, weakness, etc.) of any limitations.
3. Note any increased range of motion or instability.
4. Always compare with the other side.

Proceed to passive range of motion if abnormalities are found.

1. Ask the patient to relax and allow you to support the extremity to be examined.
2. Gently move each joint through its full range of motion.
3. Note the degree and type (pain or mechanical) of any limitation.
4. If increased range of motion is detected, perform special tests for instability as appropriate.

Always compare with the other side.

Specific Joints

• Fingers - flexion/extension; abduction/adduction
• Thumb - flexion/extension; abduction/adduction; opposition
• Wrist - flexion/extension; radial/ulnar deviation
• Forearm - pronation/supination (function of BOTH elbow and wrist)
• Elbow - flexion/extension
• Shoulder - flexion/extension; internal/external rotation; abduction/adduction (2/3 glenohumeral joint, 1/3 scapulo-thoracic)
• Hip - flexion/extension; abduction/adduction; internal/external rotation
• Knee - flexion/extension
• Ankle - flexion (plantarflexion)/extension (dorsiflexion)
• Foot - inversion/eversion
• Toes - flexion/extension
• Spine - flexion/extension; right/left bending; right/left rotation

Vascular

Pulses

1. Check the radial pulses on both sides. If the radial pulse is absent or weak, check the brachial pulses.
2. Check the posterior tibial and dorsalis pedis pulses on both sides. If these pulses are absent or weak, check the popliteal and femoral pulses.

Capillary Refill

1. Press down firmly on the patient's finger or toenail so it blanches.
2. Release the pressure and observe how long it takes the nail bed to "pink" up.
3. Capillary refill times greater than 2 to 3 seconds suggest peripheral vascular disease, arterial blockage, heart failure, or shock.

Edema, Cyanosis, and Clubbing

1. Check for the presence of edema (swelling) of the feet and lower legs.
2. Check for the presence of cyanosis (blue color) of the feet or hands.
3. Check for the presence of clubbing of the fingers.

Lymphatics

1. Check for the presence of epitrochlear lymph nodes.
2. Check for the presence of axillary lymph nodes.
3. Check for the presence of inguinal lymph nodes.

Snuffbox Tenderness (Scaphoid)

1. Identify the "anatomic snuffbox" between the extensor pollicis longus and brevis (extending the thumb makes these structures more prominent).
2. Press firmly straight down with your index finger or thumb.

Any tenderness in this area is highly suggestive of scaphoid fracture.

Drop Arm Test (Rotator Cuff)

1. Start with the patient's arm abducted 90 degrees.
2. Ask the patient to slowly lower the arm.

If the rotator cuff (especially the supraspinatus) is torn, the patient will be unable to lower the arm slowly and smoothly

Impingement Sign (Rotator Cuff)

1. Start with the patient's arm relaxed and the shoulder in neutral rotation.
2. Abduct the arm to 90 degrees.
3. Significant shoulder pain as the arm is raised suggests an impingement of the rotator cuff against the acromion.

Flexor Digitorum Superficialis Test

1. Hold the fingers in extension except the finger being tested.
2. Ask the patient to flex the finger at the proximal interphalangeal joint.
3. If the patient cannot flex the finger, the flexor digitorum superficialis tendon is cut or non-functional.

Flexor Digitorum Profundus Test

1. Hold the metacarpophalangeal and proximal interphalangeal joints of the finger being tested in extension.
2. Ask the patient to flex the finger at the distal interphalangeal joint.

If the patient cannot flex the finger, the flexor digitorum profundus tendon is cut or non-functional

Vascular and Neurologic Tests

Allen Test (Radial/Ulnar Arteries)

1. Ask the patient to make a tight fist.
2. Compress both the ulnar and radial arteries to stop blood flowing to the hand.
3. Ask the patient to open the hand.
4. Release pressure on the ulnar side. The hand should "pink" up in a few seconds unless the ulnar artery is occluded.

Phalen's Test (Median Nerve)

Ask the patient to press the backs of the hands together with the wrists fully flexed (backward praying). Have the patient hold this position for 60 seconds and then comment on how the hands feel. Pain, tingling, or other abnormal sensations in the thumb, index, or middle fingers strongly suggest carpal tunnel syndrome Repeat the process for the radial artery as indicated.

Tinel's Sign (Median Nerve)

1. Use your middle finger or a reflex hammer to tap over the carpal tunnel.
2. Pain, tingling, or electric sensations strongly suggest carpal tunnel syndrome.

Lower Extremities

Collateral Ligament Testing

1. The patient should be supine with the legs resting on the exam table.
2. Hold the leg to be examined in 20-30 degrees of flexion.
3. Place one hand laterally just below the knee. Grasp the leg near the ankle with your other hand.
4. Gently push with both hands in opposite directions to stress the knee.
5. If the knee joint "opens up" medially, the medial collateral ligament may be torn.
6. Reverse your hands and repeat the stress.
7. If the knee joint "opens up" laterally, the lateral collateral ligament may be torn.

Lachman Test (Cruciate Ligaments)

1. Ask the patient to lie supine on the exam table.
2. Grasp the thigh with one hand and the upper tibia with the other. Hold the knee in about 15 degrees of flexion.
3. Ask the patient to relax and gently pull forward on the tibia.
4. The normal knee has a distinct end point. If the tibia moves out from under the femur, the anterior cruciate ligament may be torn.
5. Repeat the test using posterior stress.
6. The normal knee has a distinct end point. If the tibia moves back under the femur, the posterior cruciate ligament may be torn.

Anterior/Posterior Drawer Test (Cruciate Ligaments)

1. Ask the patient to lie supine on the exam table with knees flexed to 90 degrees and feet flat on the table.
2. Sit on or otherwise stabilize the foot of the leg being examined.
3. Grasp the leg just below the knee with both hands and pull forward.
4. If the tibia moves out from under the femur, the anterior cruciate ligament may be torn.
5. Without changing the position of your hands, push the leg backward.
6. If the tibia moves back under the femur, the posterior cruciate ligament may be torn.

Ballotable Patella (Major Knee Effusion)

1. Ask the patient to lie supine on the exam table with leg muscles relaxed.
2. Press the patella downward and quickly release it.
3. If the patella visibly rebounds, a large knee effusion (excess fluid in the knee) is present.

Milking the Knee (Minor Knee Effusion)

1. Ask the patient to lie supine on the exam table with leg muscles relaxed.
2. Compress the suprapatellar pouch with your thumb, palm, and index finger.
3. "Milk" downward and laterally so that any excess fluid collects on the medial side.
4. Tap gently over the collected fluid and observe the effect on the lateral side, or ballot the patella as outlined above.
5. A fullness on the lateral side indicates that a small knee effusion is present.

Back

Straight Leg Raising (L5/S1 Nerve Roots)

1. Ask the patient to lie supine on the exam table with knees straight.
2. Grasp the leg near the heel and raise the leg slowly toward the ceiling.
3. Pain in an L5 or S1 distribution suggests nerve root compression or tension (radicular pain).
4. Dorsiflex the foot while maintaining the raised position of the leg.
5. Increased pain strengthens the likelihood of a nerve root problem.
6. Repeat the process with the opposite leg.
7. Increased pain on the opposite side indicates that a nerve root problem is almost certain

FABER Test (Hips/Sacroiliac Joints)

FABER stands for Flexion, Abduction, and External Rotation of the hip. This test is used to distinguish hip or sacroiliac joint pathology from spine problems.

1. Ask the patient to lie supine on the exam table.
2. Place the foot of the effected side on the opposite knee (this flexes, abducts, and externally rotates the hip).
3. Pain in the groin area indicates a problem with the hip and not the spine.
4. Press down gently but firmly on the flexed knee and the opposite anterior superior iliac crest.
5. Pain in the sacroiliac area indicates a problem with the sacroiliac joints.

Notes

1. For more information refer to A Guide to Physical Examination and History Taking, Seventh Edition by Barbara Bates, published by Lippincott in 1999. Additional reference is made to Physical Examination of the Spine and Extremities, by Stanley Hoppenfeld published in 1976 by Appleton Century Crofts.
2. It is wise to start palpation some distance from a suspected tender area. Proceed slowly and minimize palpation of tender spots once they are identified. Examine at least one joint above and below an injured area.
3. Joint motion may be limited by any combination of pain, weakness, mechanical block within the joint, deformity, contracture of the soft tissues (muscles, ligaments, musculo-tendinous structures, joint capsule, etc), and patient factors. Joint motion may be increased by instability, ligamentous laxity and/or deformity.
4. Normally the ratio of glenohumeral to scapular movement is 2:1. If the range of motion of the glenohumeral joint is reduced, the patient will increase the amount of scapular movement to compensate and the ratio will change.
5. Snuffbox Tenderness is more sensitive than an x-rays for identifying scaphoid fractures. Tenderness in this area after an injury should be treated as a fracture even if the x-rays are negative.
6. Holding the knee in flexion helps isolate the collateral ligaments. Secondary stabilizers (anterior cruciate ligament, joint capsule) come into play when the knee is in full extension. If the knee "opens up" in full extension, these secondary structures may also be damaged.
7. The Lachman Test is used by athletic trainers on the field to check for cruciate ligament injury. It is very accurate and can be done on an acutely injured knee (when the patient cannot tolerate bending the knee for a drawer test).
8. The Drawer Test is the "classic" technique to check for cruciate ligament injury. It is less accurate and cannot be done on an acutely injured knee (when the patient cannot tolerate bending). The Lachman Test is preferred in most situations.
9. The FABER Test is also known as the Fabere or Patrick test.

Examination of the Chest and Lungs

Equipment Needed

• A Stethoscope
• A Peak Flow Meter

A chest examination. This involves inspection, palpation, percussion, and auscultation (IPPA):

General Considerations

• The patient must be properly undressed and gowned for this examination.
• Ideally the patient should be sitting on the end of an exam table.
• The examination room must be quiet to perform adequate percussion and auscultation.
• Observe the patient for general signs of respiratory disease (finger clubbing, cyanosis, air hunger, etc.).
• Try to visualize the underlying anatomy as you examine the patient.

Inspection

Observe the rate, rhythm, depth, and effort of breathing. Note whether the expiratory phase is prolonged.

1. Listen for obvious abnormal sounds with breathing such as wheezes.
2. Observe for retractions and use of accessory muscles (sternomastoids, abdominals).
3. Observe the chest for asymmetry, deformity, or increased anterior-posterior (AP) diameter.
4. Confirm that the trachea is near the midline.

The thoracic cage provides the framework for the mechanics of ventilation. The normal adult thorax has an anterior-posterior (A-P) diameter less than the transverse diameter.Abnormalities of the ribs, spine, clavicles or sternum may seriously affect the ability of the respiratory muscles to cause ventilation

For example, the A-P diameter gradually increases with age, but prematurely increases in patients with COPD. The typical COPD patient’s chest has an increase in anterior-posterior diameter, referred to as a "barrel chest". A barrel chest results in a mechanical disadvantage to breathing. The chronic air trapping characteristic of the COPD process usually causes this configuration. The diaphragm is low and flat and the anterior chest elevated. Ventilation now occurs only with great effort and increased oxygen consumption.

There can also be disfiguration of the chest in other ways, such as kyphoscoliosis, scoliosis, or restricted lung expansion. These restrictive defects such as kyphosis or scoliosis reduce the patient’s ability to take a deep breath and to cough. This puts these patients at high risk after major surgery. Acute injuries to the chest wall that cause multiple rib fractures may cause flail chest and paradoxical breathing. Ventilatory failure may eventually occur without proper support.

Upon inspection the caregiver should note chest configuration, scars, trauma, movement, and the presence of chest tubes or incisions. If there are any visible chest scars, the caregivers should ask the patient about them. These are usually due to some past trauma or surgery. Caregivers should make note of any splinting of the chest caused by pain, and attempt to visualize any trauma to the lungs that may lie beneath the chest’s scars or incisions. Often, patients have experienced contusion pneumonia with hemorrhage beneath. Past chest trauma is also frequently accompanied by significant fibrosis of the lung in adjoining areas. Insertion of chest tubes in the lower chest to drain fluid from the pleural space, and those placed high to evacuate air are frequently the cause of the visible acute trauma.

Caregivers should notice the patient’s use of accessory muscles during ventilation, and pay attention to the synchrony or paradoxical motions of ventilation and count the ventilatory rate. By placing his hands on the patient’s lower chest, with thumbs just barely touching in the back, the caregiver can evaluate chest movements. The caregiver should then ask the patient to take a deep breath, and then observe if the thumbs move apart symmetrically. If not, it may be that the presence of unilateral disease is causing one side to move more than the other. Atelectasis, pneumothorax, and pleural effusions are all conditions that can cause unilateral movement.

In COPD patients due to air trapping, there is very little observable chest movement. There is also little chest movement seen in patients with restrictive disease. Crackling sounds heard around surgical incision sites when the caregiver's hands are placed on the skin can be suggestive of subcutaneous emphysema.

It should be noted that inspection for the presence of respiratory disease requires inspection of more than the thorax. The caregiver should inspect the extremities for digital clubbing and cyanosis. The neck should also be assessed for evidence of jugular venous distension (JVD). JVD occurs when the right side of the heart fails due to chronic elevation of pulmonary vascular resistance (PVR). Hypoxemia increases PVR, and over a long period of time the right ventricle cannot effectively work against this added resistance, and ventricular failure results.

Palpation

1. Identify any areas of tenderness or deformity by palpating the ribs and sternum.
2. Assess expansion and symmetry of the chest by placing your hands on the patient's back, thumbs together at the midline, and asking him to breath deeply.
3. Check for tactile fremitus.

Palpation involves touching the chest wall in order to evaluate underlying structure and function, and is used to confirm or rule out suspected problems identified by the interview, history, and initial inspection. Palpation is generally performed to:

• evaluate vocal fremitus
• estimate thoracic expansion
• assess the chest’s skin and subcutaneous tissues

The term fremitus refers to the vibrations that are transmitted through lung tissues and the chest wall whenever a vocal sound is made. When these vibrations are felt on the chest wall during palpation, they are called tactile fremitus. A comparison of these vibrations between both lungs is performed. There are differences in fremitus between men and women, and fat and thin people, but a comparison of fremitus within an individual is what needs to be noted.

To palpate for fremitus, the caregiver places the palmar aspect of the fingers or the ulnar aspect of the hand against the chest and has the patient repeat the number "99." All areas of the chest should be compared, both front and back. Fremitus should be equal over all areas of normal lung tissue except over the right upper lobe, where it increases because the bronchus is closer to the chest wall. Tactile fremitus increases in intensity whenever the density of lung tissue increases, such as in consolidation or fibrosis, and will decrease when a lung space is occupied with an increase of fluid or air (e.g., pleural effusion, pneumothorax and emphysema). The causes of abnormal tactile fremitus include:

Increased:

• Pneumonia
• Lung tumor or mass
• Pulmonary fibrosis
• Atelectasis

Decreased

Unilateral

• Bronchial obstruction with mucus plug or foreign object
• Pleural effusion
• Pneumothorax

Diffuse

• Muscular or obese chest wall
• Chronic obstructive lung disease

Palpable vibrations referred to as bronchial fremitus may be produced by the passage of air through airways containing thick secretions. Bronchial fremitus often identified during inhalation and exhalation may clear if the patient produces an effective cough. It is frequently associated with a low-pitched, coarse sound that can be heard without using a stethoscope.

Thoracic expansion

The patient’s chest wall normally expands symmetrically during deep inhalations, and the caregiver can evaluate the expansion on both the anterior and posterior chest. The caregiver first places hands over the anterolateral chest, extending the thumbs along the costal margin toward the xiphoid. To evaluate it posteriorally, the hands are placed over the posterolateral chest, with thumbs joining at approximately T8. Instruct the patient to exhale slowly and completely. Once completed, the caregiver's fingertips are secured against the sides of the patient’s chest, extending the thumbs toward the midline until their tips meet at the midline. The patient is then instructed to take a full deep breath. The CAREGIVER takes note of the distance each thumb moves away from the midline. Normal movement is about 3-5 cm for each thumb.

Bilateral reduction in chest expansion can usually be seen in patients with diseases affecting the expansion of both lungs. Unilateral reduction in expansion is indicative of a respiratory disease that impedes expansion of one lung, such as lobar consolidation, pleural effusion, atelectasis, or pneumothorax.

The skin and subcutaneous tissues of the chest wall should be palpated to ascertain the general temperature and condition of the skin. When there is air leaking from the lung into the subcutaneous tissues, fine bubbles create crackling sounds and sensations when being palpated. This condition is called subcutaneous emphysema, and the sensation produced during palpation is referred to as crepitus.

Percussion

Proper Technique

1. Hyperextend the middle finger of one hand and place the distal interphalangeal joint firmly against the patient's chest.
2. With the end (not the pad) of the opposite middle finger, use a quick flick of the wrist to strike the first finger.
3. Categorize what you hear as normal, dull, or hyperresonant.
4. Practice your technique until you can consistently produce a "normal" percussion note on your (presumably normal) partner before you work with patients.

The act of tapping on a surface in order to evaluate the underlying sound is called percussion, and percussion of the patient’s chest wall creates a sound and palpable vibration that is useful in evaluating underlying lung tissue. The vibration created by percussion penetrates the lung to a depth of about 5-7 cm below the chest wall.

To perform chest percussion, the middle finger of the left hand is placed firmly on the area to be percussed. The back of the middle phalanx is then struck with the tip of the middle finger of the right hand. Deliver the stroke from the wrist and finger joints, bending the percussing finger so its terminal phalanx is at right angles to the metacarpal bones when the blow is delivered; and so strikes the pleximeter finger in a perpendicular way.

Percussion over normal lung fields produces a low-pitch sound that is easy to hear (referred to as normal resonance). Resonance is said to be increased when the percussion note is louder and lower in pitch. Percussion may also produce a high-pitched, short in duration sound that is dull or flat, just the opposite of resonance. The percussion of the chest alone has little clinical implication; however, when it is considered with other findings, it can yield essential information.

Posterior Chest

Percuss from side to side and top to bottom using the pattern shown in the illustration. Omit the areas covered by the scapulae. Compare one side to the other looking for asymmetry. Note the location and quality of the percussion sounds you hear. Find the level of the diaphragmatic dullness on both sides. Diaphragmatic Excursion Find the level of the diaphragmatic dullness on both sides. Ask the patient to inspire deeply. The level of dullness (diaphragmatic excursion) should go down 3-5cm symmetrically.

Anterior Chest

1. Percuss from side to side and top to bottom using the pattern shown in the illustration.
2. Compare one side to the other looking for asymmetry.
3. Note the location and quality of the percussion sounds you hear.

Interpretation

Chest percussion is generally performed to evaluate the extent of diaphragmatic excursion and air-fluid levels. The note heard on percussion becomes more resonant as the diaphragm descends and the lungs fill with air. When the sound changes to a dull note, it indicates the limit of diaphragmatic descent. The less resonant the percussion notes are indicative of tissues that are denser. As a result, air naturally produces the most resonant sounds, such as is heard over a pneumothorax. Normal lung tissue produces duller sounds, with accumulation of fluids producing even duller sounds. The dullest of all sounds are heard when percussing over bone structure.

Abnormalities that increase lung tissue density, such as atelectasis or pneumonic consolidation, result in a loss of resonance and a dull percussion note above the affected area.

Auscultation

Use the diaphragm of the stethoscope to auscultate breath sounds.

Posterior Chest

1. Auscultate from side to side and top to bottom using the pattern shown in the illustration. Omit the areas covered by the scapulae.
2. Compare one side to the other looking for asymmetry.
3. Note the location and quality of the sounds you hear.

Anterior Chest

1. Auscultate from side to side and top to bottom using the pattern shown in the illustration.
2. Compare one side to the other looking for asymmetry.
3. Note the location and quality of the sounds you hear.

The next step in evaluating the patient’s chest auscultation is the process of listening for bodily sounds. Chest auscultation involves the use of a stethoscope to enhance transmission, and it takes place over the thorax to identify normal or abnormal lung sounds.

The patient, who is being examined sitting upright in a relaxed position, is instructed to breathe a bit more deeply than usual through an open mouth. Their inhalation should be active, and exhalation passive. The caregiver should proceed with the auscultation in a systematic manner, examining all lobes on the anterior, lateral, and posterior chest. Beginning at the base, the caregiver should compare sides, and work toward the lung apexes. At least one full ventilatory cycle should be evaluated at each stethoscope position.

Correct techniques for performing chest auscultation include:

• Placing the stethoscope’s bell or diaphragm directly against the chest wall
• Keeping the stethoscope’s tubing free from contact with any objects during auscultation
• Turning off any radio or television in the room
• If patient’s chest hair is thick, wetting it prior to auscultation
• Asking alert patients to sit up; rolling comatose patients on side to auscultate posterior lobes

The most common errors to be avoided during chest auscultation include:

• Listening to breath sounds through the patient’s bed clothes
• Attempting to auscultate in a noisy room
• Permitting the stethoscope’s tubing to rub against bed rails or patient’s clothing
• Misinterpreting chest hair sounds as adventitious lung sounds
• Auscultating only the areas that are convenient to get to

Numerous types of breath sounds can be heard when auscultating over the lungs. Normal breath sounds are generated mainly by the turbulence of air in the larger airways. The turbulent flow creates audible vibrations, producing sounds that are transmitted through the lung and chest wall. Normal lung tissue acts as a filter that primarily passes muffled low-frequency sounds. Normal breath sounds are "breezy" in quality, heard mainly on inspiration, and somewhat faint.

Bronchial breath sounds are considered to be abnormal sounds when they are heard over peripheral lung regions. When lung tissue becomes consolidated and increases in density, as it does in pneumonia or atelectasis, the filtering effect is lost. Diminished sounds occur when the intensity of the sound at the site of the larger airways is reduced, or when sound transmission through the lung or chest wall is decreased. The intensity of the sound is reduced with shallow or slow breathing patterns. Chronic airflow obstruction markedly reduces sound intensity throughout all lung fields. Shallow breathing patterns also contribute to decreased breath sounds in COPD patients.

As mentioned above, some of the abnormal breath sounds that may be heard by the caregiver during chest auscultation include:

• Wheezes and rhonchi--Wheezes and some rhonchi are vibrations caused by air flowing rapidly through a narrowed airway. Bronchospasm, mucosal edema, or foreign object can constrict the airway’s diameter. The pitch of the wheeze is related to the extent of airway narrowing. The greater the narrowing, the higher the pitch. Low-pitched, continuous rhonchi are frequently associated with the excessive presence of secretions in the airways. Some findings regarding the significance of expiratory wheezing include:
  
  

  1	patients with chronic airway obstruction who wheeze are more likely to show improvement after bronchodilator administration than those who don’t wheeze;
  2	less intensive wheezing is associated with a wide range of obstructive defects, while more intensive wheezing indicates moderate to severe airway obstruction;
  3	polyphonic wheezing (multiple notes) suggests many obstructed airways, such as with asthma.

  
  
• Crackles (rales)--Crackles are discontinuous, bubbling or popping sounds produced when airways pop open as air travels through fluid or small airways. Crackles can also be heard in patients without excess secretions. These occur when collapsed airways pop open during inspiration. While inspiratory crackles are considered abnormal, they can occur in normal individuals in certain situations. Crackles produced by the sudden opening of peripheral airways are called late-inspiratory crackles, and are most common in patients with respiratory diseases that reduce lung volume, including pneumonia, pulmonary edema, fibrosis, and atelectasis.

• Voice sounds--Vocal resonance should be assessed if chest inspection, palpation, percussion, or auscultation suggests any abnormalities. The patient is instructed to repeat the numbers "1, 2, 3" or "99" while the examiner uses a stethoscope to listen over the sides of the chest wall. The three types of vocal sounds heard are:
  
  

  Bronchophony	-	an increase in intensity and clarity of vocal resonance; is indicative of increased lung tissue density.
  Epophony	-	increased intensity of voice, with a nasal or bleating character; indicative of a compressed lung above a pleural effusion.
  Whispering pectoriloquy	-	high-frequency vibrations created when patients are asked to whisper "1, 2, 3) while the CAREGIVER listens over the lung periphery with a stethoscope; helpful in finding small or patchy areas of lung consolidation.
  Pleural friction rub	-	creaking or grating sound occurring when pleural surfaces are inflamed, and the roughened edges rub together during breathing; found in patients with pleurisy.

Interpretation

Breath sounds are produced by turbulent airflow. They are categorized by the size of the airways that transmit them to the chest wall (and your stethoscope). The general rule is, the larger the airway, the louder and higher pitched the sound. Vesicular breath sounds are low pitched and normally heard over most lung fields. Tracheal breath sounds are heard over the trachea. Bronchovesicular and bronchial sounds are heard in between. Inspiration is normally longer than expiration (I > E).

Breath sounds are decreased when normal lung is displaced by air (emphysema or pneumothorax) or fluid (pleural effusion). Breath sounds shift from vesicular to bronchial when there is fluid in the lung itself (pneumonia). Extra sounds that originate in the lungs and airways are referred to as "adventitious" and are always abnormal (but not always significant). (See Table)

Special Tests

Peak Flow Monitoring

Peak flow meters are inexpensive, hand-held devices used to monitor pulmonary function in patients with asthma. The peak flow roughly correlates with the FEV1.

1. Ask the patient to take a deep breath.
2. Then ask them to exhale as fast as they can through the peak flow meter.
3. Repeat the measurement 3 times and report the average.

Voice Transmission Tests

These tests are only used in special situations. This part of the physical exam has largely been replaced by the chest x-ray. All these tests become abnormal when the lungs become filled with fluid (referred to as consolidation).

Tactile Fremitus

1. Ask the patient to say "ninety-nine" several times in a normal voice.
2. Palpate using the ball of your hand.
3. You should feel the vibrations transmitted through the airways to the lung.

Increased tactile fremitus suggests consolidation of the underlying lung tissues. Bronchophony

1. Ask the patient to say "ninety-nine" several times in a normal voice.
2. Auscultate several symmetrical areas over each lung.
3. The sounds you hear should be muffled and indistinct. Louder, clearer sounds are called bronchophony.

Whispered Pectoriloquy

1. Ask the patient to whisper "ninety-nine" several times.
2. Auscultate several symmetrical areas over each lung.
3. You should hear only faint sounds or nothing at all.
4. If you hear the sounds clearly this is referred to as whispered pectoriloquy.

Egophony

1. Ask the patient to say "ee" continuously.
2. Auscultate several symmetrical areas over each lung.
3. You should hear a muffled "ee" sound. If you hear an "ay" sound this is referred to as "E -> A" or egophony.

Notes

1. For more information refer to A Guide to Physical Examination and History Taking, Seventh Edition by Barbara Bates, published by Lippincott in 1999.
2. A prolonged expiratory phase (E > I) indicates airway narrowing, as in asthma.
3. AP diameter increases somewhat with age; however, a round or "barrel" chest is often a sign of advanced emphysema.
4. The trachea will deviate to one side in cases of tension pneumothorax.
5. Additional Testing - Decreased or asymmetric diaphragmatic excursion may indicate paralysis or emphysema
6. It has been said that "a peak flow meter is to asthma as a thermometer is to fever." Peak flow measurements are used to gauge severity of asthma attacks and track the disease over time. Ideally new readings are compared to the patient's current "personal best." Readings less than 80% of "best" may indicate a need for additional therapy. Readings less than 50% may indicate an emergency situation.
7. Increased fremitus indicates fluid in the lung. Decreased fremitus indicates sound transmission obstructed by chronic obstructive pulmonary disease (COPD), fluid outside the lung (pleural effusion), air outside the lung (pneumothorax), etc. #Whispered pectoriloquy is right up there with borborygmi on this author’s list of favorite medical terms.
   

Cardiovascular Examination

Equipment Needed

• A Double-Headed, Double-Lumen Stethoscope
• A Blood Pressure Cuff
• A Moveable Light Source or Pen Light

General Considerations

• The patient must be properly undressed and in a gown for this examination.
• The examination room must be quiet to perform adequate auscultation.
• Observe the patient for general signs of cardiovascular disease (finger clubbing, cyanosis, edema, etc.).

Arterial Pulses

Rate and Rhythm

1. Compress the radial artery with your index and middle fingers.
2. Note whether the pulse is regular or irregular.
3. Count the pulse for 15 seconds and multiply by 4.
4. Count for a full minute if the pulse is irregular.
5. Record the rate and rhythm.

Amplitude and Contour

1. Observe for carotid pulsations.
2. Place your fingers behind the patient's neck and compress the carotid artery on one side with your thumb at or below the level of the cricoid cartilage. Press firmly but not to the point of discomfort.
3. Assess the following:
   - The amplitude of the pulse.
   - The contour of the pulse wave.
   - Variations in amplitude from beat to beat or with respiration.
4. Repeat on the opposite side.

Auscultation for Bruits

If the patient is late middle-aged or older, you should auscultate for bruits. A bruit is often, but not always, a sign of arterial narrowing and risk of a stroke.

1. Place the bell of the stethoscope over each carotid artery in turn. You may use the diaphragm if the patient's neck is highly contoured.
2. Ask the patient to stop breathing momentarily.
3. Listen for a blowing or rushing sound--a bruit. Do not be confused by heart sounds or murmurs transmitted from the chest.

Blood Pressure

The patient should not have eaten, smoked, taken caffeine, or engaged in vigorous exercise within the last 30 minutes. The room should be quiet and the patient comfortable.

1. Position the patient's arm so the anticubital fold is level with the heart.
2. Center the bladder of the cuff over the brachial artery approximately 2 cm above the anticubital fold. Proper cuff size is essential to obtain an accurate reading. Be sure the index line falls between the size marks when you apply the cuff. Position the patient's arm so it is slightly flexed at the elbow.
3. Palpate the radial pulse and inflate the cuff until the pulse disappears. This is a rough estimate of the systolic pressure.
4. Place the stethoscope over the brachial artery.
5. Inflate the cuff 20 to 30 mmHg above the estimated systolic pressure.
6. Release the pressure slowly, no greater than 5 mmHg per second.
7. The level at which you consistently hear beats is the systolic pressure.
8. Continue to lower the pressure until the sounds muffle and disappear. This is the diastolic pressure.
9. Record the blood pressure as systolic over diastolic (120/70).
10. Blood pressure should be taken in both arms on the first encounter.

Auscultation

1. Position the patient supine with the head of the table slightly elevated.
2. Always examine from the patient's right side. A quiet room is essential.
3. Listen with the diaphragm at the right 2nd interspace near the sternum (aortic area).
4. Listen with the diaphragm at the left 2nd interspace near the sternum (pulmonic area).
5. Listen with the diaphragm at the left 3rd, 4th, and 5th interspaces near the sternum (tricuspid area).
6. Listen with the diaphragm at the apex (mitral area).
7. Listen with the bell at the apex.
8. Listen with the bell at the left 4th and 5th interspace near the sternum.
9. Have the patient roll on their left side.
   - Listen with the bell at the apex.
   - This position brings out S3 and mitral murmurs.
10. Have the patient sit up, lean forward, and hold their breath in exhalation.
    - Listen with the diaphragm at the left 3rd and 4th interspace near the sternum.
    - This position brings out aortic murmurs.
11. Record S1, S2, (S3), (S4), as well as the grade and configuration of any murmurs ("two over six" or "2/6", "pansystolic" or "crescendo").

Interpretation

Notes

1. For more information refer to A Guide to Physical Examination and History Taking, Seventh Edition by Barbara Bates, published by Lippincott in 1999.
2. With an irregular pulse, the beats counted in any 30 second period may not represent the overall rate. The longer you measure, the more these variations are averaged out.
3. Avoid compressing both sides at the same time. This could cut off the blood supply to the brain and cause syncope. Avoid compressing the carotid sinus higher up in the neck. This could lead to bradycardia and decreased blood pressure.
4. Bell or Diaphragm? - Even though Korotkoff sounds are low frequency and should be heard better with the bell, it is often difficult to apply the bell properly to the anticubital fold. For this reason, it is common practice to use the diaphragm when taking the blood pressure.
5. Maximum Cuff Pressure - When the baseline blood pressure is already known or hypertension is not suspected, it is acceptable in adults to inflate the cuff to 200 mmHg and go directly to auscultating the blood pressure. Be aware that there could be an auscultory gap (a silent interval between the true systolic and diastolic pressures).
6. Systolic Pressure - In situations where auscultation is not possible, you can determine systolic blood pressure by palpation alone. Deflate the cuff until you feel the radial or brachial pulse return. The pressure by auscultation would be approximately 10 mmHg higher. Record the pressure indicating it was taken by palpation (60/palp).
7. Diastolic Pressure - If there is more than 10 mmHg difference between the muffling and the disappearance of the sounds, record all three numbers (120/80/45).
8. Pressure Differences - If there is more than 10 mmHg difference between the two arms, use the arm with the higher reading for subsequent measurements.
9. Sternal Angle - The sternal angle is taken to be 5cm above the right atrium. A jugular pulse 10cm above the sternal angle equates to a central enous pressure of 15cm of water.
10. Left Sternal Border - The left 3rd, 4th, and 5th interspaces are considered the tricuspid area and are referred to as the Lower Left Sternal Border or LLSB.

Examination of the Head and Neck

Equipment Needed

• An Otoscope
• Tongue Blades
• Cotton Tipped Applicators
• Latex Gloves

General Considerations

The head and neck exam is not a single, fixed sequence. Different portions are included depending on the examiner and the situation.

Head

1. Look for scars, lumps, rashes, hair loss, or other lesions.
2. Look for facial asymmetry, involuntary movements, or edema.
3. Palpate to identify any areas of tenderness or deformity.

Ears

1. Inspect the auricles and move them around gently. Ask the patient if this is painful.
2. Palpate the mastoid process for tenderness or deformity.
3. Hold the otoscope with your thumb and fingers so that the ulnar aspect of your hand makes contact with the patient.
4. Pull the ear upward and backward to straighten the canal.
5. Insert the otoscope to a point just beyond the protective hairs in the ear canal. Use the largest speculum that will fit comfortably.
6. Inspect the ear canal and middle ear structures noting any redness, drainage, or deformity.
7. Insufflate the ear and watch for movement of the tympanic membrane.
8. Repeat for the other ear.

Nose

It is often convenient to examine the nose immediately after the ears using the same speculum.

1. Tilt the patient's head back slightly. Ask him to hold his breath for the next few seconds.
2. Insert the otoscope into the nostril, avoiding contact with the septum.
3. Inspect the visible nasal structures and note any swelling, redness, drainage, or deformity.
4. Repeat for the other side.

Throat

It is often convenient to examine the throat using the otoscope with the speculum removed.

1. Ask the patient to open his mouth.
2. Using a wooden tongue blade and a good light source, inspect the inside of the patient’s mouth including the buccal folds and under the tongue. Note any ulcers, white patches (leukoplakia), or other lesions.
3. If abnormalities are discovered, use a gloved finger to palpate the anterior structures and floor of the mouth.
4. Inspect the posterior oropharynx by depressing the tongue and asking the patient to say "Ah." Note any tonsillar enlargement, redness, or discharge.

Neck

1. Inspect the neck for asymmetry, scars, or other lesions.
2. Palpate the neck to detect areas of tenderness, deformity, or masses.
3. The musculoskeletal exam of the neck is covered elsewhere in this COURSE.

Lymph Nodes

1. Systematically palpate with the pads of your index and middle fingers for the various lymph node groups.
   1. Preauricular - In front of the ear
   2. Postauricular - Behind the ear
   3. Occipital - At the base of the skull
   4. Tonsillar - At the angle of the jaw
   5. Submandibular - Under the jaw on the side
   6. Submental - Under the jaw in the midline
   7. Superficial (Anterior) Cervical - Over and in front of the sternomastoid muscle
   8. Supraclavicular - In the angle of the sternomastoid and the clavicle
   
   
2. The deep cervical chain of lymph nodes lies below the sternomastoid and cannot be palpated without getting underneath the muscle:
   

   1. Inform the patient that this procedure will cause some discomfort. 2. Hook your fingers under the anterior edge of the sternomastoid muscle. 3. Ask the patient to bend his neck toward the side you are examining. 4. Move the muscle backward and palpate for the deep nodes underneath.

   
   
3. Note the size and location of any palpable nodes and whether they were soft or hard, non-tender or tender, and mobile or fixed.

Thyroid Gland

1. Inspect the neck looking for the thyroid gland. Note whether it is visible and symmetrical. A visibly enlarged thyroid gland is called a goiter.
2. Move to a position behind the patient.
3. Identify the cricoid cartilage with the fingers of both hands.
4. Move downward two or three tracheal rings while palpating for the isthmus.
5. Move laterally from the midline while palpating for the lobes of the thyroid.
6. Note the size, symmetry, and position of the lobes, as well as the presence of any nodules. The normal gland is often not palpable.

Facial Tenderness

1. Ask the patient to tell you if these maneuvers cause excessive discomfort or pain.
2. Press upward under both eyebrows with your thumbs.
3. Press upward under both maxillas with your thumbs.
4. Excessive discomfort on one side or significant pain suggests sinusitis.

Sinus Transillumination

1. Darken the room as much as possible.
2. Place a bright otoscope or other point light source on the maxilla.
3. Ask the patient to open his mouth and look for an orange glow on the hard palate.
4. A decreased or absent glow suggests that the sinus is filled with something other than air.

Temporomandibular Joint

1. Place the tips of your index fingers directly in front of the tragus of each ear.
2. Ask the patient to open and close his mouth.
3. Note any decreased range of motion, tenderness, or swelling.

Notes

1. Page numbers refer to Barbara Bates' A Guide to Physical Examination and History Taking, Seventh Edition , published by Lippincott in 1999.
2. The line of hairs in the external ear is a good approximation of where the bony canal begins. Inserting the speculum beyond this point can be very painful.

Insufflation means to change the pressure in the outer ear. The tympanic membrane normally moves easily in response to this pressure change. Lack of movement is a sign of negative pressure or fluid in the middle ear. Bates refers to this procedure as pneumatic otoscopy.

Examination of the Eye

Equipment Needed A Snellen Eye Chart or Pocket Vision Card An Ophthalmoscope

Visual Acuity

In cases of eye pain, injury, or visual loss, always check visual acuity before proceeding with the rest of the exam or putting medications in your patient’s eyes.

1. Allow the patient to use his glasses or contact lens if available. You are interested in the patient's best-corrected vision.
2. Position the patient 20 feet in front of the Snellen eye chart (or hold a Rosenbaum pocket card at a 14 inch "reading" distance).
3. Have the patient cover one eye at a time with a card.
4. Ask the patient to read progressively smaller letters until he can go no further.
5. Record the smallest line the patient read successfully (20/20, 20/30, etc.)
6. Repeat with the other eye.
7. Unexpected/unexplained loss of acuity is a sign of serious ocular pathology.

Inspection

Observe the patient for ptosis, exophthalmos, lesions, deformities, or asymmetry. Ask the patient to look up and pull down both lower eyelids to inspect the conjunctiva and sclera. Next spread each eye open with your thumb and index finger. Ask the patient to look to each side and downward to expose the entire bulbar surface. Note any discoloration, redness, discharge, or lesions. Note any deformity of the iris or lesion of the cornea. If you suspect the patient has conjunctivitis, be sure to wash your hands immediately. Viral conjunctivitis is highly contagious - protect yourself!

Visual Fields

Screen Visual Fields by Confrontation

1. Stand two feet in front of the patient and have him look into your eyes.
2. Hold your hands to the side halfway between you and the patient.
3. Wiggle the fingers on one hand.
4. Ask the patient to indicate on which side he sees your fingers move.
5. Repeat two or three times to test both temporal fields.
6. If an abnormality is suspected, test the four quadrants of each eye while asking the patient to cover the opposite eye with a card.

Extraocular Muscles

Corneal Reflections

1. Shine a light from directly in front of the patient.
2. The corneal reflections should be centered over the pupils.
3. Asymmetry suggests extraocular muscle pathology.

Extraocular Movement

1. Stand or sit 3 to 6 feet in front of the patient.
2. Ask the patient to follow your finger with his eyes without moving his head.
3. Check gaze in the six cardinal directions using a cross or "H" pattern.
4. Check convergence by moving your finger toward the bridge of the patient's nose.

Pupillary Reactions

Light

1. Dim the room lights as necessary.
2. Ask the patient to look into the distance.
3. Shine a bright light obliquely into each pupil in turn.
4. Look for both the direct (same eye) and consensual (other eye) reactions.
5. Record pupil size in mm and any asymmetry or irregularity.

Accommodation

If the pupillary reactions to light are diminished or absent, check the reaction to accommodation (near reaction):

1. Hold your finger about 10cm from the patient's nose.
2. Ask him to alternate looking into the distance and at your finger.
3. Observe the pupillary response in each eye.

Ophthalmoscopic Exam

Darken the room as much as possible. Adjust the ophthalmoscope so that the light is no brighter than necessary. Adjust the aperture to a plain white circle. Set the diopter dial to zero unless you have determined a better setting for your eyes. Use your left hand and left eye to examine the patient's left eye. Use your right hand and right eye to examine the patient's right eye. Place your free hand on the patient's shoulder for better control. Ask the patient to stare at a point on the wall or the corner of the room. Look through the ophthalmoscope and shine the light into the patient's eye from about two feet away. You should see the retina as a "red reflex." Follow the red color to move within a few inches of the patient's eye. Adjust the diopter dial to bring the retina into focus. Find a blood vessel and follow it to the optic disk. Use this as a point of reference. Inspect outward from the optic disk in at least four quadrants and note any abnormalities. Move nasally from the disk to observe the macula. Repeat for the other eye.

Special Tests

Upper Eyelid Eversion

This procedure is performed when a foreign body is suspected. Ask the patient to look down. Gently grasp the patient's upper eyelashes and pull them out and down. Place the shaft of an applicator or tongue blade about 1 cm from the lid margin. Pull the lid upward using the applicator as a fulcrum to turn the lid "inside out." Do not press down on the eye itself. Pin the eyelid in this position by pressing the lashes against the eyebrow while you examine the palpebral conjunctiva. Ask the patient to blink several times to return the lid to normal

Notes

1. Visual acuity is reported as a pair of numbers (20/20) where the first number is how far the patient is from the chart and the second number is the distance from which the "normal" eye can read a line of letters. For example, 20/40 means that at 20 feet the patient can only read letters a "normal" person can read from twice that distance.
2. For more information refer to A Guide to Physical Examination and History Taking, Seventh Edition by Barbara Bates, published by Lippincott in 1999.
3. You may, instead of wiggling a finger, raise one or two fingers (unilaterally or bilaterally) and have the patient state how many fingers (total, both sides) he sees. To test for neglect, on some trials wiggle your right and left fingers simultaneously. The patient should see movement in both hands.
4. PERRLA is a common abbreviation that stands for "Pupils Equal Round Reactive to Light and Accommodation." The use of this term is so routine that it is often used incorrectly. If you did not specifically check the accommodation reaction use the term PERRL. Pupils with a diminished response to light but a normal response to accommodation (Argyll-Robertson Pupils) are a sign of neurosyphilis.
5. Diopters are used to measure the power of a lens. The ophthalmoscope actually has a series of small lens of different strengths on a wheel (positive diopters are labeled in green, negative in red). When you focus on the retina you "dial-in" the correct number of diopters to compensate for both the patient's and your own vision. For example, if both you and your patient wear glasses with -2 diopter correction you should expect to set the dial to -2 with your glasses on or -4 with your glasses off.

Examination of the Abdomen

Equipment Needed

• A Stethoscope

General Considerations

The patient should have an empty bladder. The patient should be lying supine on the exam table and appropriately draped. The examination room must be quiet to perform adequate auscultation and percussion. Watch the patient's face for signs of discomfort during the examination.

Use the appropriate terminology to locate your findings: o Right Upper Quadrant (RUQ) o Right Lower Quadrant (RLQ) o Left Upper Quadrant (LUQ) o Left Lower Quadrant (LLQ) o Midline:    - Epigastric    - Periumbilical    - Suprapubic Disorders in the chest will often manifest with abdominal symptoms. It is always wise to examine the chest when evaluating an abdominal complaint. Consider the inguinal/rectal examination in males. Consider the pelvic/rectal examination in females.

Inspection

1. Look for scars, striae, hernias, vascular changes, lesions, or rashes.
2. Look for movement associated with peristalsis or pulsations.
3. Note the abdominal contour. Is it flat, scaphoid, or protuberant?

Auscultation

1. Place the diaphragm of your stethoscope lightly on the abdomen.
2. Listen for bowel sounds. Are they normal, increased, decreased, or absent?
3. Listen for bruits over the renal arteries, iliac arteries, and aorta.

Percussion

1. Percuss in all four quadrants using proper technique.
2. Categorize what you hear as tympanitic or dull. Tympany is normally present over most of the abdomen in the supine position. Unusual dullness may be a clue to an underlying abdominal mass.

Liver Span

Percuss downward from the chest in the right midclavicular line until you detect the top edge of liver dullness. Percuss upward from the abdomen in the same line until you detect the bottom edge of liver dullness. Measure the liver span between these two points. This measurement should be 6-12 cm in a normal adult.

Splenic Dullness

Percuss the lowest costal interspace in the left anterior axillary line. This area is normally tympanitic. Ask the patient to take a deep breath and percuss this area again. Dullness in this area is a sign of splenic enlargement.

Palpation

General Palpation

1. Begin with light palpation. At this point you are mostly looking for areas of tenderness. The most sensitive indicator of tenderness is the patient's facial expression (so watch the patient's face, not your hands). Voluntary or involuntary guarding may also be present.
2. Proceed to deep palpation after surveying the abdomen lightly. Try to identify abdominal masses or areas of deep tenderness.

Palpation of the Liver

Standard Method

1. Place your fingers just below the right costal margin and press firmly.
2. Ask the patient to take a deep breath.
3. You may feel the edge of the liver press against your fingers. Or it may slide under your hand as the patient exhales. A normal liver is not tender.

Alternate Method

This method is useful when the patient is obese or when the examiner is small compared to the patient.

1. Stand by the patient's chest.
2. "Hook" your fingers just below the costal margin and press firmly.
3. Ask the patient to take a deep breath.
4. You may feel the edge of the liver press against your fingers.

Palpation of the Aorta

1. Press down deeply in the midline above the umbilicus.
2. The aortic pulsation is easily felt on most individuals.
3. A well defined, pulsatile mass, greater than 3 cm across, suggests an aortic aneurysm.

Palpation of the Spleen

1. Use your left hand to lift the lower rib cage and flank.
2. Press down just below the left costal margin with your right hand.
3. Ask the patient to take a deep breath.
4. The spleen is not normally palpable on most individuals.

Special Tests

Rebound Tenderness

This is a test for peritoneal irritation.

1. Warn the patient what you are about to do.
2. Press deeply on the abdomen with your hand.
3. After a moment, quickly release pressure.
4. If it hurts more when you release, the patient has rebound tenderness.

Costovertebral Tenderness

CVA tenderness is often associated with renal disease.

1. Warn the patient what you are about to do.
2. Have the patient sit up on the exam table.
3. Use the heel of your closed fist to strike the patient firmly over the costovertebral angles.
4. Compare the left and right sides.

Shifting Dullness

This is a test for peritoneal fluid (ascites).

1. Percuss the patient's abdomen to outline areas of dullness and tympany.
2. Have the patient roll away from you.
3. Percuss and again outline areas of dullness and tympany. If the dullness has shifted to areas of prior tympany, the patient may have excess peritoneal fluid.

Psoas Sign

This is a test for appendicitis.

1. Place your hand above the patient's right knee.
2. Ask the patient to flex the right hip against resistance.
3. Increased abdominal pain indicates a positive psoas sign.

Obturator Sign

This is a test for appendicitis.

1. Raise the patient's right leg with the knee flexed.
2. Rotate the leg internally at the hip.
3. Increased abdominal pain indicates a positive obturator sign.

Notes

1. For more information refer to A Guide to Physical Examination and History Taking, Seventh Edition by Barbara Bates, published by Lippincott in 1999.
2. Auscultation should be done prior to percussion and palpation since bowel sounds may change with manipulation. Since bowel sounds are transmitted widely in the abdomen, auscultation of more than one quadrant is not usually necessary. If you hear them, they are present, period.
3. Tenderness felt in the RLQ when palpation is performed on the left is called Rovsing's Sign and suggests appendicitis. Rebound tenderness referred from the left to the RLQ also suggests this disorder.
4. Small amounts of peritoneal fluid are not usually detectable on physical exam.

Examination of the Breast

Equipment Needed

• None

General Considerations The patient must be properly gowned for this examination. All upper body clothing should be removed. Breast tissue changes with age, pregnancy, and menstrual status. The procedure described here can also be used for self-examination using a mirror for inspection.

Inspection

1. Give a brief overview of the examination to patient.
2. Have the patient sit at end of exam table.
3. Ask the patient to remove gown to her waist, assist only if needed.
4. Have the patient relax arms to her side.
5. Examine visually for following:
   o Approximate symmetry
   o Dimpling or retraction of skin
   o Swelling or discoloration
   o Orange peel effect on skin
   o Position of nipple
6. Observe the movement of breast tissue during the following maneuvers:
   o Shrug shoulders with hands on hips
   o Slowly raise arms above head
   o Lean forward with hands on knees (large breasts only)
7. Have the patient replace the gown.
8. Reassure the patient. If the exam is normal so far, say so.

Palpation

1. Have the patient lie supine on the exam table.
2. Ask the patient to remove the gown from one breast and place her hand behind her head on that side.
3. Begin to palpate at junction of clavicle and sternum using the pads of the index, middle, and ring fingers. If open sores or discharge are visible, wear gloves.
4. Press breast tissue against the chest wall in small circular motions. Use very light pressure to assess superficial layer, moderate pressure for middle layer and firm pressure for deep layers.
5. Palpate the breast in overlapping vertical strips. Continue until you have covered the entire breast including the axillary "tail."
6. Palpate around the areola and the depression under the nipple. Press the nipple gently between thumb and index finger and make note of any discharge.
7. Lower the patient's arm and palpate for axillary lymph nodes.
8. Have the patient replace the gown and repeat on the other side.
9. Reassure the patient; discuss the results of the exam.

Notes

1. For more information refer to A Guide to Physical Examination and History Taking, Seventh Edition by Barbara Bates, published by Lippincott in 1999.
2. Bates refers to circular or clock face patterns. These are considered to be inferior to the "lawn mower" pattern of vertical strips and should not be used.

Examination of the Female Pelvis

Equipment Needed

• Exam Table Equipped with Stirrups
• Flexible Light Source
• Vaginal Specula in Various Sizes
• Warm Running Water
• Lubricating Jelly

General Considerations

• The patient must have an empty bladder.
• The patient must be appropriately gowned and draped.
• Use non-sterile gloves on both hands. Double-glove your dominant hand if you intend to perform a rectal or rectovaginal exam.
• Properly dispose of soiled equipment and supplies.
• Both male and female examiners should be chaperoned by a female assistant.
• Always tell the patient what you are about to do before you do it.
• The breast exam is usually done just before routine pelvic exams.

Positioning the Patient

1. Start with the patient lying supine on the exam table with the head elevated 30 to 45 degrees.
2. Assist the patient in placing her heels in the stirrups. Adjust the angle and length to "fit" the patient.
3. Have the patient slide her hips down until she contacts your hand at the edge of the table.
4. Have the patient relax her knees outward just beyond the angle of the stirrups.

External Exam

1. Uncover the vulva by moving the center of the drape away from you. Try to avoid creating a "screen" with the drape pulled tight between the patient's knees.
2. Announce what you are going to do and then touch the patient on the thigh with the back of your hand before proceeding.
3. Inspect the outer genitalia for redness, swelling, lesions, masses, or infestations.
4. Gently palpate the labia majora and minora.
5. Inspect the labia, the folds between them, and the clitoris.
6. Note any redness, swelling, lesions, or discharge.
7. Reassure the patient, if the exam is normal so far, say so.

Internal Exam

Speculum Exam

Warm and lubricate the speculum by holding it under running tap water. Announce what you are going to do and then touch the patient on the thigh with the speculum before proceeding. Expose the introitus by spreading the labia from below using the index and middle fingers of the non-dominant hand (peace sign). Insert the speculum at a 45 degree angle pointing slightly downward. Avoid contact with the anterior structures. Once past the introitus, rotate the speculum to a horizontal position and continue insertion until the handle is almost flush with the perineum. Open the "bills" of the speculum 2 or 3 cm using the thumb lever. Position the bills so that the cervix "falls" in between. Secure the speculum by turning the thumb nut (metal speculum) or clicking the ratchet mechanism (plastic speculum). Do not move the speculum while it is locked open. Observe the cervix and vaginal walls for lesions or discharge. Obtain specimens for culture and cytology as indicated. Withdraw the speculum slightly to clear the cervix. Loosen the speculum and allow the "bills" to fall together. Continue to withdraw while rotating the speculum to 45 degrees. Again, avoid contact with the anterior structures. Replace the drape while you prepare for the rest of the exam. Reassure the patient, if the exam is normal so far, say so

Bimanual Exam

1. Apply a small amount of lubricant to the index and middle fingers of your dominant hand.
2. Uncover the vulva and lower abdomen by moving the center of the drape away from you.
3. Announce what you are going to do and then touch the patient on the thigh with the back of your hand before proceeding.
4. Spread the labia and insert your lubricated index and middle fingers into the vagina. Avoid contact with the anterior structures.
5. Place your other hand on the patient's lower abdomen.
6. Examine the cervix:
   1. Palpate the cervix with your index finger noting size, shape, and consistency.
   2. Gently move the cervix side to side between your fingers and note mobility and tenderness.
   3. Gently lift the cervix forward and note mobility and tenderness.
7. Examine the anterior uterine fundus:
   1. Continue to lift the cervix with the vaginal hand.
   2. Press downward with the abdominal hand and palpate the uterus (if possible).
   3. Note consistency and tenderness. Attempt to estimate uterine size.
8. Examine the adnexal structures:
   1. Pull back vaginal hand to clear cervix.
   2. Reposition vaginal hand into the right fornix, palm up.
   3. Sweep the right ovary downward with the abdominal hand 3 or 4 cm medial to the iliac crest.
   4. Gently "trap" the ovary between the fingers of both hands (if possible). Note its size and shape along with any other palpable adnexal structures.
   5. Pull back and repeat on the left side.
9. Replace the drape and assist the patient to remove her feet from the stirrups and sit up.
10. Reassure the patient, if the exam is normal, say so.
11. Leave the room and allow the patient to dress before continuing with the consultation.

Notes

1. The rectal and rectovaginal exam are part of normal pelvic examinations, but are not covered here..
2. For more information refer to A Guide to Physical Examination and History Taking, Seventh Edition by Barbara Bates, published by Lippincott in 1999.
3. You will obtain a Papanicolaou (Pap) smear and other specimens as part of most pelvic exams. Pap smears are analyzed for cervical cancer cells by a cytology technician under the supervision of a pathologist.
4. Tenderness with cervical motion is an important sign of pelvic disease. You should both observe the patient's face and ask her if the examination is painful in any way.
5. Your ability to palpate the uterus and ovaries will depend on the patient's anatomy, the size of your hands, and your level of skill.

Neurologic Examination

Equipment Needed

• Reflex Hammer
• 128 and 512 (or 1024) Hz Tuning Forks
• A Snellen Eye Chart or Pocket Vision Card
• Pen Light or Otoscope
• Wooden Handled Cotton Swabs
• Paper Clips

General Considerations

• Always consider left to right symmetry
• Consider central vs. peripheral deficits
• Organize your thinking into seven categories:
  1. Mental Status
  2. Cranial Nerves
  3. Motor
  4. Coordination and Gait
  5. Reflexes
  6. Sensory
  7. Special Tests

Mental Status

The Mini Mental Status Examination is a useful screening tool.

Cranial Nerves

Observation

• Ptosis (III)
• Facial Droop or Asymmetry (VII)
• Hoarse Voice (X)
• Articulation of Words (V, VII, X, XII)
• Abnormal Eye Position (III, IV, VI)
• Abnormal or Asymmetrical Pupils (II, III)

I - Olfactory

Not Normally Tested

II - Optic

• Examine the Optic Fundi
  Covered elsewhere..
• Test Visual Acuity
  1. Allow the patient to use his glasses or contact lens if available. You are interested in the patient's best-corrected vision.
  2. Position the patient 20 feet in front of the Snellen eye chart (or hold a Rosenbaum pocket card at a 14 inch "reading" distance).
  3. Have the patient cover one eye at a time with a card.
  4. Ask the patient to read progressively smaller letters until he can go no further.
  5. Record the smallest line the patient read successfully (20/20, 20/30, etc.) [2]
  6. Repeat with the other eye.
• Screen Visual Fields by Confrontation
  0.Stand two feet in front of the patient and have him look into your eyes.
  1. Hold your hands about one foot away from the patient's ears, and wiggle a finger on one hand.
  2. Ask the patient to indicate on which side he sees the finger move.
  3. Repeat two or three times to test both temporal fields.
  4. If an abnormality is suspected, test the four quadrants of each eye while asking the patient to cover the opposite eye with a card.
  
  
• Test Pupillary Reactions to Light
  0. Dim the room lights as necessary.
  1. Ask the patient to look into the distance.
  2. Shine a bright light obliquely into each pupil in turn.
  3. Look for both the direct (same eye) and consensual (other eye) reactions.
  4. Record pupil size in mm and any asymmetry or irregularity.
  5. If abnormal, proceed with the test for accommodation.
• Test Pupillary Reactions to Accommodation
  0. Hold your finger about 10cm from the patient's nose.
  1. Ask him to alternate looking into the distance and at your finger.
  2. Observe the pupillary response in each eye.

III - Oculomotor

• Observe for Ptosis
• Test Extraocular Movements
  1. Stand or sit 3 to 6 feet in front of the patient.
  2. Ask the patient to follow your finger with his eyes without moving his head.
  3. Check gaze in the six cardinal directions using a cross or "H" pattern.
  4. Pause during upward and lateral gaze to check for nystagmus.
  5. Check convergence by moving your finger toward the bridge of the patient's nose.
• Test Pupillary Reactions to Light (See Above)

IV - Trochlear

Test Extraocular Movements (Inward and Down Movement, See Above)

V - Trigeminal

• Test Temporal and Masseter Muscle Strength
  1. Ask patient to both open his mouth and clench his teeth.
  2. Palpate the temporal and masseter muscles as he does this.
• Test the Three Divisions for Pain Sensation
  1. Explain what you intend to do.
  2. Use a suitable sharp object to test the forehead, cheeks, and jaw on both sides.
  3. Substitute a blunt object occasionally and ask the patient to report "sharp" or "dull."
• If you find an abnormality then:
  1. Test the three divisions for temperature sensation with a tuning fork heated or cooled by water.
  2. Test the three divisions for sensation to light touch using a wisp of cotton.
• Test the Corneal Reflex
  1. Ask the patient to look up and away.
  2. From the other side, touch the cornea lightly with a fine wisp of cotton.
  3. Look for the normal blink reaction of both eyes.
  4. Repeat on the other side.
  5. Use of contact lens may decrease this response.

VI - Abducens

Test Extraocular Movements (Lateral Movement, See Above)

VII - Facial

• Observe for Any Facial Droop or Asymmetry
• Ask Patient to do the following. Note any lag, weakness, or asymmetry:
  1. Raise eyebrows
  2. Close both eyes to resistance
  3. Smile
  4. Frown
  5. Show teeth
  6. Puff out cheeks
• Test the Corneal Reflex (See Above)

VIII - Acoustic

• Screen Hearing
  1. Face the patient and hold out your arms with your fingers near each ear.
  2. Rub your fingers together on one side while moving the fingers noiselessly on the other.
  3. Ask the patient to tell you when and on which side he hears the rubbing.
  4. Increase intensity as needed and note any asymmetry.
  5. If abnormal, proceed with the Weber and Rinne tests.
• Test for Lateralization (Weber)
  1. Use a 512 Hz or 1024 Hz tuning fork.
  2. Start the fork vibrating by tapping it on your opposite hand.
  3. Place the base of the tuning fork firmly on top of the patient's head.
  4. Ask the patient where the sound appears to be coming from (normally in the midline).
• Compare Air and Bone Conduction (Rinne)
  1. Use a 512 Hz or 1024 Hz tuning fork.
  2. Start the fork vibrating by tapping it on your opposite hand.
  3. Place the base of the tuning fork against the mastoid bone behind the ear.
  4. When the patient no longer hears the sound, hold the end of the fork near the patient's ear (air conduction is normally greater than bone conduction).
• Vestibular Function is Not Normally Tested

IX - Glossopharyngeal

See Vagus Nerve

X - Vagus

• Listen to the patient's voice. Is it hoarse or nasal?
• Ask Patient to Swallow
• Ask Patient to Say "Ah"
  o Watch the movements of the soft palate and the pharynx.
• Test Gag Reflex (Unconscious/Uncooperative Patient)
  1. Stimulate the back of the throat on each side.
  2. It is normal to gag after each stimulus.

XI - Accessory

• From behind, look for atrophy or asymmetry of the trapezius muscles.
• Ask patient to shrug shoulders against resistance.
• Ask patient to turn his head against resistance. Watch and palpate the sternomastoid muscle on the opposite side.

XII - Hypoglossal

• Listen to the articulation of the patient's words.
• Observe the tongue as it lies in the mouth
• Ask patient to:
  1. Protrude tongue
  2. Move tongue from side to side

Motor

Observation

• Involuntary Movements
• Muscle Symmetry
  o Left to Right
  o Proximal vs. Distal
• Atrophy
  o Pay particular attention to the hands, shoulders, and thighs.
• Gait

Muscle Tone

1. Ask the patient to relax.
2. Flex and extend the patient's fingers, wrist, and elbow.
3. Flex and extend patient's ankle and knee.
4. There is normally a small, continuous resistance to passive movement.
5. Observe for decreased (flaccid) or increased (rigid/spastic) tone.

Muscle Strength

• Test strength by having the patient move against your resistance.
• Always compare one side to the other.
• Grade strength on a scale from 0 to 5 "out of five":
  
  

  Grading Motor Strength
  Grade	Description
  0/5	No muscle movement
  1/5	Visible muscle movement, but no movement at the joint
  2/5	Movement at the joint, but not against gravity
  3/5	Movement against gravity, but not against added resistance
  4/5	Movement against resistance, but less than normal
  5/5	Normal strength

  
  
• Test the following:
  1. Flexion at the elbow (C5, C6, biceps)
  2. Extension at the elbow (C6, C7, C8, triceps)
  3. Extension at the wrist (C6, C7, C8, radial nerve)
  4. Squeeze two of your fingers as hard as possible ("grip," C7, C8, T1)
  5. Finger abduction (C8, T1, ulnar nerve)
  6. Opposition of the thumb (C8, T1, median nerve)
  7. Flexion at the hip (L2, L3, L4, iliopsoas)
  8. Adduction at the hips (L2, L3, L4, adductors)
  9. Abduction at the hips (L4, L5, S1, gluteus medius and minimus)
  10. Extension at the hips (S1, gluteus maximus)
  11. Extension at the knee (L2, L3, L4, quadriceps)
  12. Flexion at the knee (L4, L5, S1, S2, hamstrings)
  13. Dorsiflexion at the ankle (L4, L5)
  14. Plantar flexion (S1)

Pronator Drift

1. Ask the patient to stand for 20-30 seconds with both arms straight forward, palms up, and eyes closed.
2. Instruct the patient to keep the arms still while you tap them briskly downward.
3. The patient will not be able to maintain extension and supination (and "drift into pronation) with upper motor neuron disease.

Coordination and Gait

Rapid Alternating Movements

1. Ask the patient to strike one hand on the thigh, raise the hand, turn it over, and then strike it back down as fast as possible.
2. Ask the patient to tap the distal thumb with the tip of the index finger as fast as possible.
3. Ask the patient to tap your hand with the ball of each foot as fast as possible.

Point-to-Point Movements

1. Ask the patient to touch your index finger and his nose alternately several times. Move your finger about as the patient performs this task.
2. Hold your finger still so that the patient can touch it with one arm and finger outstretched. Ask the patient to move his arm and return to your finger with his eyes closed.
3. Ask the patient to place one heel on the opposite knee and run it down the shin to the big toe. Repeat with the patient's eyes closed.

Romberg

1. Be prepared to catch the patient if he is unstable.
2. Ask the patient to stand with the feet together and eyes closed for 5-10 seconds without support.
3. The test is said to be positive if the patient becomes unstable (indicating a vestibular or proprioceptive problem).

Gait

Ask the patient to:

1. Walk across the room, turn and come back
2. Walk heel-to-toe in a straight line
3. Walk on his toes in a straight line
4. Walk on his heels in a straight line
5. Hop in place on each foot
6. Do a shallow knee bend
7. Rise from a sitting position

Reflexes

Deep Tendon Reflexes

• The patient must be relaxed and positioned properly before starting.
• Reflex response depends on the force of your stimulus. Use no more force than you need to provoke a definite response.
• Reflexes can be reinforced by having the patient perform isometric contraction of other muscles (clenched teeth).
• Reflexes should be graded on a 0 to 4 "plus" scale:
  
  

  Tendon Reflex Grading Scale
  Grade	Description
  0	Absent
  1+ or +	Hypoactive
  2+ or ++	"Normal"
  3+ or +++	Hyperactive without clonus
  4+ or ++++	Hyperactive with clonus

  
  
• Biceps (C5, C6)
  1. The patient's arm should be partially flexed at the elbow with the palm down.
  2. Place your thumb or finger firmly on the biceps tendon.
  3. Strike your finger with the reflex hammer.
  4. You should feel the response even if you can't see it.
• Triceps (C6, C7)
  1. Support the upper arm and let the patient's forearm hang free.
  2. Strike the triceps tendon above the elbow with the broad side of the hammer.
  3. If the patient is sitting or lying down, flex the patient's arm at the elbow and hold it close to the chest.
• Brachioradialis (C5, C6)
  1. Have the patient rest the forearm on the abdomen or lap.
  2. Strike the radius about 1-2 inches above the wrist.
  3. Watch for flexion and supination of the forearm.
• Abdominal (T8, T9, T10, T11, T12)
  1. Use a blunt object such as a key or tongue blade.
  2. Stroke the abdomen lightly on each side in an inward and downward direction above (T8, T9, T10) and below the umbilicus (T10, T11, T12).
  3. Note the contraction of the abdominal muscles and deviation of the umbilicus towards the stimulus.
• Knee (L2, L3, L4)
  1. Have the patient sit or lie down with the knee flexed.
  2. Strike the patellar tendon just below the patella.
  3. Note contraction of the quadriceps and extension of the knee.
• Ankle (S1, S2)
  1. Dorsiflex the foot at the ankle.
  2. Strike the Achilles tendon.
  3. Watch and feel for plantar flexion at the ankle.

Clonus

If the reflexes seem hyperactive, test for ankle clonus:

1. Support the knee in a partly flexed position.
2. With the patient relaxed, quickly dorsiflex the foot.
3. Observe for rhythmic oscillations.

Plantar Response (Babinski)

1. Stroke the lateral aspect of the sole of each foot with the end of a reflex hammer or key.
2. Note movement of the toes, normally flexion (withdrawal).
3. Extension of the big toe with fanning of the other toes is abnormal. This is referred to as a positive Babinski.

Sensory

General

• Explain each test before you do it.
• Unless otherwise specified, the patient's eyes should be closed during the actual testing.
• Compare symmetrical areas on the two sides of the body.
• Also compare distal and proximal areas of the extremities.
• When you detect an area of sensory loss, map out its boundaries in detail.

Vibration

• Use a low-pitched tuning fork (128Hz).
  1. Test with a non-vibrating tuning fork first to ensure that the patient is responding to the correct stimulus.
  2. Place the stem of the fork over the distal interphalangeal joint of the patient's index fingers and big toes.
  3. Ask the patient to tell you if he feels the vibration.
  
  
• If vibration sense is impaired proceed proximally:
  1. Wrists
  2. Elbows
  3. Medial malleoli
  4. Patellars
  5. Anterior superior iliac spines
  6. Spinous processes
  7. Clavicles

Subjective Light Touch

• Use your fingers to touch the skin lightly on both sides simultaneously.
• Test several areas on both the upper and lower extremities.
• Ask the patient to tell you if there is difference from side to side or other "strange" sensations.

Position Sense

1. Grasp the patient's big toe and hold it away from the other toes to avoid friction.
2. Show the patient "up" and "down."
3. With the patient's eyes closed ask the patient to identify the direction you move the toe.
4. If position sense is impaired move proximally to test the ankle joint.
5. Test the fingers in a similar fashion.
6. If indicated move proximally to the metacarpophalangeal joints, wrists, and elbows.

Dermatomal Testing

If vibration, position sense, and subjective light touch are normal in the fingers and toes you may assume the rest of this exam will be normal.

Pain

• Use a suitable sharp object to test "sharp" or "dull" sensation.
• Test the following areas:
  1. Shoulders (C4)
  2. Inner and outer aspects of the forearms (C6 and T1)
  3. Thumbs and little fingers (C6 and C8)
  4. Front of both thighs (L2)
  5. Medial and lateral aspect of both calves (L4 and L5)
  6. Little toes (S1)

Temperature

• Often omitted if pain sensation is normal.
• Use a tuning fork heated or cooled by water and ask the patient to identify "hot" or "cold."
• Test the following areas:
  1. Shoulders (C4)
  2. Inner and outer aspects of the forearms (C6 and T1)
  3. Thumbs and little fingers (C6 and C8)
  4. Front of both thighs (L2)
  5. Medial and lateral aspect of both calves (L4 and L5)
  6. Little toes (S1)

Light Touch

• Use a fine whisp of cotton or your fingers to touch the skin lightly.
• Ask the patient to respond whenever a touch is felt.
• Test the following areas:
  1. Shoulders (C4)
  2. Inner and outer aspects of the forearms (C6 and T1)
  3. Thumbs and little fingers (C6 and C8)
  4. Front of both thighs (L2)
  5. Medial and lateral aspect of both calves (L4 and L5)
  6. Little toes (S1)

Discrimination

Since these tests are dependent on touch and position sense, they cannot be performed when the tests above are clearly abnormal.

• Graphesthesia
  1. With the blunt end of a pen or pencil, draw a large number in the patient's palm.
  2. Ask the patient to identify the number.
• Stereognosis
  1. Use as an alternative to graphesthesia.
  2. Place a familiar object in the patient's hand (coin, paper clip, pencil, etc.).
  3. Ask the patient to tell you what it is.
• Two Point Discrimination
  1. Use in situations where more quantitative data is needed, such as following the progression of a cortical lesion.
  2. Use an opened paper clip to touch the patient's finger pads in two places simultaneously.
  3. Alternate irregularly with one point touch.
  4. Ask the patient to identify "one" or "two."
  5. Find the minimal distance at which the patient can discriminate.

Notes

1. For more information refer to A Guide to Physical Examination and History Taking, Seventh Edition by Barbara Bates, published by Lippincott in 1999.
2. Visual acuity is reported as a pair of numbers (20/20) where the first number is how far the patient is from the chart and the second number is the distance from which the "normal" eye can read a line of letters. For example, 20/40 means that at 20 feet the patient can only read letters a "normal" person can read from twice that distance.
3. You may, instead of wiggling a finger, raise one or two fingers (unilaterally or bilaterally) and have the patient state how many fingers (total, both sides) they see. To test for neglect, on some trials wiggle your right and left fingers simultaneously. The patient should see movement in both hands.
4. PERRLA is a common abbreviation that stands for "Pupils Equal Round Reactive to Light and Accommodation." The use of this term is so routine that it is often used incorrectly. If you did not specifically check the accommodation reaction use the term PERRL. Pupils with a diminished response to light but a normal response to accommodation (Argyll-Robertson Pupils) are a sign of neurosyphilis.
5. Nystagmus is a rhythmic oscillation of the eyes. Horizontal nystagmus is described as being either "leftward" or "rightward" based on the direction of the fast component.
6. Testing Pain Sensation - Use a new object for each patient. Break a wooden cotton swab to create a sharp end. The cotton end can be used for a dull stimulus. Do not go from patient to patient with a safety pin. Do not use non-disposable instruments such as those found in certain reflex hammers. Do not use very sharp items such as hypodermic needles.
7. Central vs Peripheral - With a unilateral central nervous system lesion (stroke), function is preserved over the upper part of the face (forehead, eyebrows, eyelids). With a peripheral nerve lesion (Bell's Palsy), the entire face is involved.
8. The hearing screening procedure presented by Bates on page 181 is more complex than necessary. The technique presented in this syllabus is preferred.
9. Deviation of the tongue or jaw is toward the side of the lesion.
10. Although it is often tested, grip strength is not a particularly good test in this context. Grip strength may be omitted if finger abduction and thumb opposition have been tested.
11. The "anti-gravity" muscles are difficult to assess adequately with manual testing. Useful alternatives include: walk on toes (plantarflexion); rise from a chair without using the arms (hip extensors and knee extensors); step up on a step, once with each leg (hip extensors and knee extensors).
12. Subjective light touch is a quick survey for "strange" or asymmetrical sensations only, not a formal test of dermatomes.

Mini Mental Status Examination

The "Mini" Mental Status Exam is a quick way to evaluate cognitive function. It is often used to screen for dementia or monitor its progression. [See Page 120 in Bates A Guide to Physical Examination, 7th Ed ]
Folstein Mini Mental Status Examination
Task Instructions Scoring
Date Orientation "Tell me the date" Ask for omitted items. One point each for year, season, date, day of week, and month 5
Place Orientation "Where are you?" Ask for omitted items. One point each for state, county, town, building, and floor or room 5
Register 3 Objects Name three objects slowly and clearly. Ask the patient to repeat them. One point for each item correctly repeated 3
Serial Sevens Ask the patient to count backwards from 100 by 7. Stop after five answers. (Or ask them to spell "world" backward.) One point for each correct answer (or letter) 5
Recall 3 Objects Ask the patient to recall the objects mentioned above. One point for each item correctly remembered 3
Naming Point to your watch and ask the patient "what is this?" Repeat with a pencil. One point for each correct answer 2
Repeating a Phrase Ask the patient to say "no ifs, ands, or buts." One point if successful on first try 1
Verbal Commands Give the patient a plain piece of paper and say "Take this paper in your right hand, fold it in half, and put it on the floor." One point for each correct action 3
Written Commands Show the patient a piece of paper with "CLOSE YOUR EYES" printed on it. One point if the patient's eyes close 1
Writing Ask the patient to write a sentence. One point if sentence has a subject, a verb, and makes sense 1
Drawing Ask the patient to copy a pair of intersecting pentagons onto a piece of paper. One point if the figure has ten corners and two intersecting lines 1
Scoring A score of 24 or above is considered normal. 30
Adapted from Folstein et al, Mini Mental State, J PSYCH RES 12:196-198 (1975)

As a result of the patient interview and examination, the caregivers can form some initial conclusions regarding a diagnosis of the patient’s condition. These conclusions will prove valuable in helping the caregivers assure that the therapeutic modalities prescribed by the physician are best suited for the patient.

In addition to interviewing and examining patients, caregivers need to be able to evaluate a patient’s chest x-rays. This module is not intended to provide you with the interpretive skills of a radiologic technologist. It is designed to enable you to recognize structures and basic areas of normality and abnormality

Diagnostic radiographs of the chest are an important part of the evaluation of the patient with respiratory complaints.

In a chest radiograph, you can see the patient’s heart left-center, and the left ventricle will appear to be most prominent. The other features that can be observed include:

• Aortic knob: It lies superior to the heart, and can be distinguished by its rounded appearance.
• Right atrium: Along with the superior vena cava, it appears to be the heart’s border on the right side.
• Descending aorta: Appears posteriorly to the heart in lateral view x-rays.
• Lungs: Appear on both side of the chest, and have the look of translucent shadows.
• Diaphragm: This dome-shaped structure can be seen located along the inferior border of the chest’s cavity. Its right side is slightly (2 cm) higher because of the location of the liver.
• Hilum: Can be seen in the medial area of the chest, and its pulmonary vessels and lymph nodes appear to be a branching density.

X-rays also reveal the presence of infiltrates, which are usually caused by blood or body fluids accumulating in the vascular space. These appear as darkened or clouded areas on the radiographs. When the alveoli fill with fluids or the tissues consolidate around the bronchus, that area will be clearly visible on the radiograph. If a density or clouded area appears to be anterior to the heart, the border will be obscured. Densities lying posteriorly to the heart do not obscure the heart’s border.

The most common and useful chest x-rays are the posterior-anterior (PA) views; however, bedside radiographs sometimes are required as a result of the patient’s condition. These portable x-rays don’t allow as much control of positioning or film exposure, and in AP films, the heart usually appears larger because it is a greater distance from the film plate.

Some of the other radiographic procedures that can facilitate diagnosis of a patient include:

• Fluoroscopy: This technique permits the heart and lungs can be viewed in motion. It facilitates the diagnosis of paralysis of any part of the diaphragm since it can be observed moving during the patient’s breathing process.
• Inspiration/Expiration Films: These radiographs are taken as the patient breathes maximally in and out. They can help confirm the presence of bronchial obstructions, including tumors or blebs frequently seen in COPD patients.
• Oblique views: Taken at approximately a 45° angle to the film plate, these chest views allow a review of the heart’s more difficult to see areas, and facilitate assessing its size. Effective viewing of the lung apices is permitted by the lordotic view, which involves lifting the clavicles away from the lung tissue.
• Computed tomography (CT): This technique utilizes computer technology to evaluate "slices" of lung density data. It is valuable and effective for: observing focal lung lesions beneath bony areas, identifying the bullae and blebs seen in pulmonary emphysema, helping physicians analyze the lesions seen in lung cancer prior to performing surgery.
• Magnetic resonance imaging (MRI): This non-invasive painless technique involving electromagnetic field technology has proven to be valuable in evaluating the possibility of cancer in the chest wall and mediastinum; and has proven useful for diagnosing thoracic aneurysms, congenital anomalies, and major vessels of the aorta.
• Bronchoscopy: This technique involves insertion of a fiberoptic endoscope into the bronchi, and has become most valuable for diagnosing the presence of lung cancer. The following are 3D images via virtual bronchoscopy:

3D Imaging of the Trachea

3D imaging of a normal trachea	3D virtual bronchoscopy of normal airway
Tracheal stenosis with virtual imaging	Tracheal stenosis with 3D virtual bronchoscopy

• Computed tomography (CT): This technique utilizes computer technology to evaluate "slices" of lung density data. It is valuable and effective for: observing focal lung lesions beneath bony areas, identifying the bullae and blebs seen in pulmonary emphysema, and helping physicians analyze the lesions seen in lung cancer prior to performing surgery.
• Magnetic resonance imaging (MRI): This non-invasive painless technique involving electromagnetic field technology has proven to be valuable in evaluating the possibility of cancer in the chest wall and mediastinum; and has proven useful for diagnosing thoracic aneurysms, congenital anomalies, and major vessels of theaorta.

Mucus Production and Sputum

Mucus is produced in the goblet cells and the bronchial glands. The goblet cells are located in the epithelial layer of the tracheobronchial tree while the bronchial glands are located below the epithelial layer. The fluid secreted by the bronchial glands is much more watery than the goblet cell fluid.

Mucus is expelled by coughing or clearing the throat. Once it is expelled, mucus is called sputum. The major components of sputum are 95% water, 2% mucus, 1% carbohydrates, and 1% lipids. The two layers of sputum are called the sol layer and the gel layer.

The sol layer is in direct contact with the cilia of the lungs which act to propel particles out of the tracheobronchial tree. The gel layer, which is thicker, lies adjacent to the inner bronchial surface. The process of moving secretions out of the tracheobronchial tree is called mucociliary transport. Some of the factors that slow down the transport process are cigarette smoking, dehydration, and positive pressure ventilation.

The group of drugs designed to break down mucus are called mucolytic agents. These agents work primarily in four ways: some increase the depth of the sol layer such as water and saline, some decrease the viscosity of the gel layer such as acetylcysteine, some decrease the adhesiveness of the gel layer such as propylene glycol, and some increase ciliary activity such as the sympathomimetic drugs.

Analysis: Sputum Culture and Sensitivity

As mentioned, sputum is the material brought up by coughing and clearing of the respiratory tract. Sputum may contain mucus, blood, pus, cellular debris, and microorganisms. Sputum that is used for laboratory analysis must be obtained from the bronchi, and not from the back of the throat, postnasal region, or the oral cavity. Secretions expelled from the lungs and tracheobronchial tree are specifically referred to as phlegm.

A pure sputum specimen is one that is not contaminated by saliva from the oropharynx or by secretions from the nasal sinuses. A sputum sample must be obtained by either having the patient expectorate it or by suctioning the patient. The best time to obtain a specimen is in the early morning since secretions tend to collect in the patient's chest during sleep. To obtain a fresh, uncontaminated specimen the patient should be instructed to rinse out the mouth with water. The patient can then take several deep breaths and cough from the diaphragm. Approximately 1 to 3 ml of sputum should be collected in a sterile container.

If the laboratory detects a large number of epithelial cells that indicate saliva in the specimen, it will be discarded and another one will have to be obtained. Some maintain that a specimen containing >25 squamous epithelial cells/lpf is indicative of oropharyngeal contamination. A preponderance of neutrophils, ciliated epithelial cells, or alveolar macrophages with <10 squamous epithelial cells/lpf is indicative of lower respiratory secretions.

If the patient cannot produce a specimen because of minimal secretions or an inadequate cough, they will either need to be suctioned or have the sputum induced. A sputum induction can be done by giving an aerosol nebulizer treatment containing either normal or hypertonic sodium chloride and/or performing postural drainage or chest percussion. If this fails the patient will have to be nasotracheally suctioned if the physician so orders.

After the specimen is properly obtained and placed in a sterile container, it is sent to the laboratory for analysis. The specimen should reach the laboratory within 1 hour of collection. Once it reaches the lab, the technician will place it on nutrient-containing media that will enhance the growth of the microorganism. A sample of sputum is then applied as a very thin layer to a microscope slide and then stained with a violet stain known as a gram stain. Bacteria that retain a violet color after they're stained with crystal violet and washed with ethanol are gram-positive. If the bacteria lose the violet color, they are referred to as gram-negative.

The color, number, and morphologic appearance of the cells make it possible to identify the genus of the organism. Gram staining helps the physician select an initial antibiotic until the lab completes a full culture and sensitivity testing of the organisms. The results of the gram stain may lead to a presumptive diagnosis of bacterial pneumonia if large numbers are found.

After the specimen is identified, the laboratory will test its sensitivity to antimicrobial drugs so that the physician can select a specific drug to combat the infection. The laboratory will use either an automated system or disc diffusion to determine an organism's susceptibility to a drug. The automated system will give a minimum inhibitory concentration (MIC). The MIC is an exact quantitative value where the smaller the number, the more effective the drug will be.

In the disc diffusion method, the organism is grown on agar in a Petri dish and various drugs are placed on the agar to determine responses. If the drug is effective, a clear area will appear around the disc of the drug. This area where the drug has eradicated the organism is called the zone of inhibition. The larger the zone, the more sensitive the microorganism is to the antibiotic. A final report will include the organisms cultured and what drugs they're sensitive to.

On the report, normal flora should be differentiated from pathogens. Different areas of the body have differing amounts and types of flora. Also, the number of colonies (a group of bacteria in a culture that derived from a single organism) that were grown should be reviewed. When reporting sputum specimens, the laboratory will report these as "normal flora" or they will identify the specific pathogens involved. Other descriptive terms used include scant, moderate, or numerous to differentiate the quantity.

Gram Stain

Bacterial organisms are broadly classified into one of four groups by performing a gram stain. The classifications include:

1. Gram-positive rods
2. Gram-positive cocci
3. Gram-negative rods
4. Gram-negative cocci

The bacteria can be then be further classified as being either aerobic or anaerobic.

Cultures and Sensitivity Tests

Cultures involve the propagation of microorganisms or living tissue cells in special media conducive to their growth. These tests are performed whenever identification of specific organisms is needed to prescribe therapies. Most cultures can be completed within two or three days, but some, such as mycobacterium tuberculosis, can take as long as eight weeks. Once the organism has been identified, it is necessary to conduct sensitivity tests to ascertain the most appropriate and effective antibiotic therapy.

Using a technique called the acid-fast stain generally tests for the presence of mycobacterium organisms. Urinalysis is used to diagnose diseases involving the liver, kidney, cardiovascular, and endocrine systems. Pleural fluid analysis is used to distinguish transudate and exudate fluids in the pleural space.

The Carbon Dioxide Challenge Test is used to measure the increase or decrease in minute ventilation caused by breathing various concentrations of carbon dioxide under normal oxygen conditions. The test is particularly useful in determining the effects of carbon dioxide on the respiratory center of patients suspected of decreased ventilatory drive to carbon dioxide. Other names for the carbon dioxide challenge test include the C02 response test and the hypercapnic challenge test.

The Carbon Dioxide Challenge Test can be measured by either the open-circuit technique or the closed-circuit technique. In the open-circuit technique the patient breathes various concentrations (1% to 7%) carbon dioxide from a demand valve or reservoir until a steady state is reached.

With the closed-circuit technique or rebreathing technique, the patient rebreathes from a one-way circuit. A 6 to 10 Liter anesthesia bag is filled with a volume equal to the patient's vital capacity plus 1 Liter of a gas mixture containing 7% C02 and 93% 02. The 7% C02 is chosen to approximate average mixed venous concentrations of C02, and the 93% 02 is chosen to eliminate concern for hypoxia during the test.

After normal breathing followed by a full expiration, valves are turned that provide the anesthesia bag as a reservoir for ventilation during the test. Exhaled gases are returned to the bag. End-tidal C02 is monitored during the test. If occlusion pressures are desired (pressure generated at the mouth with an occluded airway), the inspiratory portion of the circuit is occluded by means of a Starling resistor at random intervals throughout the test. The output of a pressure transducer is then recorded on a high speed recorder. Changes in minute ventilation are monitored and plotted against the End-tidal C02 to obtain a response curve. The test continues until:

• 4 minutes have elapsed or
• the patient's end-tidal CO2 concentration equals 9% or
• when the patient complains of dyspnea
• the first 30 seconds of rebreathing are excluded from data analysis.

Preparations for the test will include the avoidance of respiratory stimulants such as caffeine containing beverages (coffee, tea, cola), theophylline preparations, medroxyprogesterone, and protriptyline should be discontinued for at least 12 hours before testing unless the effects of these substances on ventilatory response to C02 is desired. Complications may include a generalized vasodilatation that may cause flushing, diaphoresis, and headaches.

The normal response to increased levels of PaC02 is a linear increase in minute ventilation of approximately 3 L/min/mm Hg. The normal range of response may vary from 1 to 6 L/min/mm Hg PC02. In some patients with COPD the response to elevated C02 may be reduced. These patients with C02 retention receive their primary stimulus to breath from the hypoxemic response. Other patients with myxedema, obesity-hypoventilation syndrome, obstructive sleep apnea, and idiopathic hypoventilation may also show a marked decreased response to hypoxemia or hypercapnia.

Occlusion pressure is the pressure generated at the mouth during the first 100 msec of an inspiratory effort against an occluded airway. The occlusion pressure measured at 100 msec is a relatively direct indicator of the output of the respiratory center to the diaphragm and is independent of airflow obstruction. Normal values for a normocapnic P100 is 2.6 cm H20 (range 1.5-5). The occlusion pressure may increase at a rate of approximately 0.5-6 cm H20 for every mm increase in end-tidal C02. Some patients with COPD may show no increase in their P100 in response to elevated PC02 levels.

Hypercapnic patients who exhibit PC02 values greater than 55 mm Hg at rest will not usually provide a sufficient sample to plot the ventilatory response by the end of the test (63 mm Hg). Voluntary erratic breathing will yield misleading data. Interpretation may be difficult since a wide range of normal responses exist.

Pulmonary Function Testing (PFT's) refers to a series of diagnostic studies done in an outpatient setting that can yield valuable information to your physician. When properly performed and interpreted they can help diagnose the cause of a symptom (such as shortness of breath), the extent of a disease (such as Emphysema), and help determine the efficacy of therapy (such as how effective are corticosteroids in treating a patient with Idiopathic Pulmonary Fibrosis).

A patient’s pulmonary function status can deteriorate without exhibiting any changes in symptoms. For example, asthmatic patients recovering from an acute attack can be asymptomatic for some time prior to flow rates returning to normal. The spirometry of PFT can determine the patient’s vital capacity, with expiratory flow rates being useful in identifying airway obstructions.

The Spirogram

There are three parts to a complete PFT. Most basic is the Spirogram. In this test a patient blows into the testing apparatus as rapidly and as hard as they can for as long as they are able. Two good trials are required for an accurate test. This test measures the air flow and is useful in detecting the presence and severity of such obstructive airways diseases as Asthma. If the Spirogram is abnormal, a bronchodilator medication is usually given to the patient, and the Spirogram is then repeated. Any improvement after the inhalation of the Bronchodilator agent suggests the patient may benefit in the chronic use of similar agents.

Lung Volume Determinations

Lung Volume determinations are the second component of a complete PFT. This is not a forced maneuver. The patient breathes a special gas mixture with a normal respiratory effort for about three minutes and then slowly exhales. By using mathematical calculations, it is possible to determine not only the volume of gas in the lung, but also to subdivide the total volume of gas in the lung into clinically useful compartments. If there is less then the normal amount of gas in the lung, a restrictive disease such as Idiopathic Pulmonary Fibrosis may be suggested.

The Diffusion Capacity

The Diffusion Capacity is the final component of a complete PFT. In this test the patient exhales fully, the breathes in another special mixture of gas. A component of this gas mixture rapidly diffuses from the airway into the blood. When the patient exhales after about 10 seconds of breath holding , the expired breath is collected in an air tight bag and analyzed. The results of the diffusion capacity test correlates with the body's ability to extract oxygen from the lungs. It is the most difficult of the Pulmonary Function Tests to accurately interpret, but a low diffusion capacity is usually a sign of advanced disease in patients with Emphysema or Idiopathic Pulmonary Fibrosis.

Ventilatory Status and Parameters

It is important that the attending caregivers be aware of their patient’s ability to breathe spontaneously and without any ventilatory assistance. Patients need to be able to increase the depth and rate of their breathing without becoming fatigued. Patients without an adequate ventilatory reserve to deal with normal daily stressors are at risk for developing life-threatening respiratory distress.

Caregivers can evaluate this reserve by evaluating the data obtained from performing various bedside assessment procedures, including:

• Tidal Volume (VT): By having a patient breathe normally through a respirometer, the caregivers can obtain the patient’s tidal volume. The VT is obtained by averaging the expired volume over the period of a minute. It can be determined as a calculation of minute ventilation, and normally should be at least 5-7 ml/kg of the patient’s body weight to be sufficient to maintain adequate ventilation without assistance.
• Minute Ventilation (VE): This can be measured by counting the patient’s respiratory while he exhales when breathing normally through a spirometer for one minute. The total amount of exhaled gas in a minute equals the patient’s minute ventilation. Total average tidal volume is then calculated by dividing VE by the respiratory rate. 5-10 l/min is considered a normal.
• Forced Vital Capacity (FVC): To ascertain ventilatory reserve under stress (forced vital capacity) have the patient inspire maximally and then exhale as fast and completely as possible through the spirometer. If the FVC is less than 10-15 ml/kg body weight, the patient may need ventilatory assistance.
• Maximal Inspiratory Force (MIF): Patients need to have an acceptable level of respiratory muscle strength in order to maintain an adequate vital capacity. MIF can be measured by using a pressure manometer. Patients need to be strong enough to exert a MIF of at least -20 cm H2O to be considered normal and adequate.
• Peak Expiratory Flow Rate (PEFR): The existence and degree of airway obstruction and the patient’s response to aerosolized bronchodilators can be measured at bedside by evaluating the patient’s maximum rate of air flow expelled during a forced expiration.

Conclusion

Pulmonary Function Testing (PFT's)is thus useful in diagnosis of the cause of symptoms (such as shortness of breath). PFT's can determine the potential efficacy of therapy (will a Bronchodilator work), suggest the severity of a lung disease and be used to follow the course of a lung illness and its response to therapy.

Introduction

Arterial Blood Gas Analysis(ABG's) along with Pulmonary Function Testing(PFT's) form the two cornerstones of the physiologic testing of lung function. PFT's have been discussed elsewhere and share with ABG's the ability to help with the diagnosis and treatment of a vast variety of diseases and disorders.

Sample technique

To obtain a blood sample for ABG's, a needle is placed in an artery. The Radial Artery is the usual source of the blood sample used for ABG's. This artery runs in the wrist and is close enough to the skin surface to be easily entered with a small needle. The arterial puncture is usually preceded with an Allen's Test that assures an adequate collateral blood flow through the wrist. The sample is collected under sterile conditions and run through an analyzer.

Sample Analysis and Results

The analyzer produces three main measurements: arterial pH, paO2 and paCO2.

The arterial pH is a measure of the body's acid-base equilibrium. The body possesses many powerful mechanisms that attempt to maintain the pH within a very narrow range. Any major alteration of the pH can prove fatal and treatments must be begun to normalize the pH as rapidly as possible.

The arterial paO2 measures the oxygenation of the blood. A low paO2 can also prove fatal and appropriate oxygen therapy is usually given to correct a low paO2.

The arterial paCO2 measures the body’s ability to excrete the metabolic byproduct CO2(carbon dioxide). The ability to excrete CO2 is one of the major respiratory functions of the lung. An elevated paCO2 may suggest a problem with lung ventilation that could progress to require mechanical ventilation. A low paCO2 may suggest a metabolic problem.

Thus, ABG's provide a valuable window on a range of potentially life-threatening problems and are essential in following the complex course of critically ill patients

Pulse Oximetry Home Evaluation Test

Oxygen therapy is the administration of oxygen at concentrations greater than room air, with the intention of treating or preventing the symptoms and manifestations of hypoxia in the home or extended-care facility.

The Pulse Oximetry Home Evaluation test or Desaturation Oximetry test is used to determine the patient's level of arterial oxygenation at rest and during exercise, movement, or sleep. The oximetry report generally includes heart rate, resting 02 saturation, and the lowest functional 02 saturation during whatever event is being monitored. A correlation of oxyhemoglobin measured by blood oximetry ABGs and pulse oximetry should be made to accurately verify the results. The external ECG should correlate within 5 beats/minute of the pulse oximeter's pulse display.

Guidelines for reimbursement of home oxygen therapy state that a resting arterial p02 < or = to 55 torr or a resting oxygen saturation (Sp02%) < or = to 88% in association with specific clinical conditions (cor pulmonale, congestive heart failure, or erythrocythemia with hematocrit > 56) with evidence of improvement with oxygen therapy qualify a patient for continuous oxygen therapy reimbursement. Guidelines for reimbursement for nocturnal and exercise oxygen therapy state that 02 saturations during exercise or sleep that fall to < or = 88% that improve with oxygen therapy will be reimbursed.

Because of the limitations of pulse oximetry, decisions regarding oxygen therapy should not be made on the basis of pulse oximetry alone. Assessment of the Pa02 by arterial blood gases should be done also. Some patients with Pa02 55 torr may be denied oxygen therapy if the decision was based on pulse oximetry measurements alone.

Arterial blood gas analysis is indicated whenever there is a major change in the patient's cardiopulmonary status. These measurements should be repeated in 1-3 months after in-hospital oxygen therapy is begun, to determine long-term use. Once long-term use has been documented, repeated arterial blood gas analysis or oxygen saturation measurements are unnecessary unless there is a need to follow the course of the disease, to assess changes in the patient's clinical status, or to facilitate changes in the amount of oxygen.

Equipment commonly used for in-home oxygen use will include low-flow oxygen delivery devices such as nasal cannulas, transtracheal oxygen catheters, oxygen reservoir cannulae (nasal or pendant), and demand oxygen delivery devices. Oxygen supply systems will include oxygen concentrators, liquid oxygen systems, and compressed gas cylinders. Under normal circumstances low-flow oxygen systems without humidifiers do not pose an increased risk for infection and do not need to be replaced on a routine basis.

Precautions or possible complications from the use of home oxygen may include:

1. Oxygen administration may lead to an increase in PaCO2 in those patients who are C02 retainers.
2. Inadequate instruction in home oxygen therapy may result in problems.
3. Complications may result from use of nasal cannulae or transtracheal catheters.
4. Increased oxygen concentrations may increase possible fire hazards.
5. Bacterial contamination may result from certain nebulizers and humidification systems if not properly maintained.
6. Physical hazards can result from unsecured cylinders, ungrounded equipment, or mishandling of liquid oxygen (resulting in burns).

Clinical assessment of the patient receiving in-home oxygen therapy should be routinely performed. Patients should be visited/monitored at least once a month by credentialed personnel unless conditions require more frequent visits. All oxygen delivery equipment should be checked daily for proper functioning, prescribed flow rates, oxygen percentage, liquid or compressed gas content, and backup supply. The nurse or RCP should visit on a monthly basis and go over needed information for the patient and family to operate the equipment correctly.

Ventilation/perfusion lung scanning involves the generation of an image by radiation emitted from radioisotopes introduced into the lungs. The V/Q scan involves two tests that are almost always combined; the Ventilation scintiscan and the Perfusion scintiscan. When combined together, they are commonly known as a V/Q scan.

The primary indication for lung ventilation and perfusion imaging is the detection of acute pulmonary emboli. In the Ventilation scintiscan, lung fields are viewed following the inhalation of a radioactive gas in order to determine the distribution of ventilation. In the Perfusion scintiscan, radioactive particles are injected into the blood stream intravenously and scanned as the particles pass through the pulmonary bloodstream.

The Ventilation Scintiscan is sometimes known as the radionuclide ventilation lung scan, aerosol lung scan, ventilation lung scan, and the xenon lung scan. In this procedure the patient takes one or several breaths of a radioactive gas usually containing xenon. Multiple images of the lungs are then taken to assess lung ventilation. Radio-aerosols labeled with technetium can also be used instead of xenon gas.

The ventilation scintiscan measures the distribution pattern and the volume of ventilation within the lungs. In addition to testing for pulmonary emboli along with the perfusion scan, lung ventilation imaging is also helpful in quantifying regional pulmonary ventilation. This can be helpful when used in patients with severe obstructive lung disease or who are being considered for lung resection surgery. Normal findings in the test will show a homogeneous distribution of activity throughout the lungs.
The Perfusion Scintiscan is sometimes known as the perfusion lung scan, perfusion-ventilation scan, pulmonary scan, and radionuclide perfusion lung scan. In this procedure the patient receives an intravenous injection of albumin particles that are tagged or labeled with a radioactive marker, such as iodine or technetium-99m (99mTc). The albumin particles are trapped by the small arterioles of the pulmonary circulation providing a pattern of gamma radiation that indicates pulmonary perfusion. Multiple images of the lungs are then acquired to assess lung perfusion.

Before administering the perfusion scintiscan, the patient will have blood work drawn prior to the injection of the radioactive material. The patient will also have a routine chest radiograph performed within 12 hours prior to imaging or receive one immediately after. Caution should be taken before administering the test for patients with known primary or secondary pulmonary hypertension. The radioactive albumin can worsen the underlying condition temporarily. The perfusion scan is nearly always combined with a lung ventilation scan to detect patterns of segmental perfusion deficits that occur alongside normal regional ventilation. This is characteristic of pulmonary emboli.

A number of diseases create abnormalities in either ventilation or perfusion or both. The evaluation of a suspected pulmonary embolism should begin with a ventilation-perfusion (V/Q) lung scan. When an embolus is lodged within a pulmonary vessel, a marked decrease or absence of pulmonary perfusion occurs in the involved area. In the first 24 to 48 hours however, ventilation to the area is maintained. This combination of decreased perfusion along with normal ventilation is called a non-matching ventilation/perfusion defect. If the area of decreased perfusion becomes infarcted, then it is called a matching ventilation/perfusion defect.

The V/Q scan should be interpreted in conjunction with a current chest radiograph along with clinical assessment. The V/Q scintigraphic patterns can usually be classified in four categories: high probability, intermediate probability (indeterminate), low probability, and normal.

1. A high probability interpretation is usually indicative of pulmonary embolism. The positive predictive value of a high probability lung scan result is around 90%. In the majority of patients a high probability lung scan confirms the diagnosis of pulmonary embolism. A pulmonary angiographic confirmation will usually not be necessary unless the scan result does not correlate with the clinical picture.
2. A normal/near normal pattern indicates that a pulmonary embolism is very unlikely. If the V/Q scan is normal/near normal, no further workup or treatment for pulmonary embolism is needed.
3. An intermediate probability (indeterminate) result may or may not be an indication of a pulmonary embolism. For this group of patients a pulmonary angiogram is needed for further evaluation.

A low probability lung scan makes the possibility of pulmonary embolism remote when verification by clinical assessment is lacking. If clinical signs are evident however, an angiogram should be performed.

Blood Panels

Blood panels are group of tests used to determine the patient’s condition. These groups of tests may be general in scope or targeted to check for a specific disease or organ function. The analysis most often can be performed using a small sample of blood. Four new laboratory panels were approved by the American Medical Association Current Procedural Terminology (CPT) Board in 1996. These include the electrolyte panel, the hepatic function panel, the basic metabolic panel, and the comprehensive metabolic panel.

Initially, the major blood panel test was the Chemistry Panel. This test is usually called Chem- followed by a number (Chem-7, Chem-16, Chem-25) depending on how many tests are ordered. The Chemistry Panel is a very common test to find out if a person may have diabetes, kidney problems, problem with electrolytes, liver problems, and/or elevation of cholesterol or triglycerides. It may also include blood proteins, calcium, phosphorus, serum iron, and muscle enzymes. The number of tests included in the panel for each laboratory is different. The Chemistry Panel is now being superseded by the Basic and the Comprehensive Metabolic panel and is not being used to describe this grouping of tests.

1. Hepatic Function Panel. This panel focuses on liver function and is used to diagnose and monitor conditions such as hepatitis. Gallstones may also be detected using this panel. These tests may also be used to check for liver disease while the patient is being treated with certain drugs. The Hepatic Function Panel includes:

1. Hepatic Function Panel A
2. Albumin; serum
3. Bilirubin; total and direct
4. Phosphatase; alkaline
5. Transferase; aspartate amino (AST) (SGOT)
6. Transferase; alanine amino (ALT) (SGPT)

2. Electrolyte Panel - The electrolyte panel contains tests which indicate of the amount of water and salt in the body. These tests include sodium, potassium, chloride and carbon dioxide. Some of the disorders that lead to imbalances of the electrolytes include dehydration from vomiting or diarrhea, and kidney disease. Certain drugs such as diuretics may also affect the concentration of electrolytes in the body. The Electrolytes Panel includes:

1. Carbon dioxide (bicarbonate)
2. Chloride; blood
3. Potassium; serum
4. Sodium; serum

3. Basic Metabolic Panel - This group of tests is an extension of the electrolyte panel and includes tests to measure kidney function and glucose metabolism. The additional tests include creatinine, glucose and BUN. The Basic Metabolic Panel consists of:

1. Carbon dioxide (bicarbonate)
2. Chloride; blood
3. Creatinine; blood
4. Glucose; quantitative
5. Potassium; serum
6. Sodium; serum
7. Urea nitrogen; quantitative

4. Comprehensive Metabolic Panel - This group of tests combines almost all of the tests included in the Basic Metabolic and Hepatic Panels. Bone health is also checked by evaluating calcium, phosphate and alkaline phosphatase. The Comprehensive Metabolic Panel includes:

1. Albumin; serum
2. Bilirubin; total
3. Calcium; total
4. Chloride; blood
5. Creatinine; blood
6. Glucose; quantitative
7. Phosphatase; alkaline
8. Potassium; serum
9. Protein; total, except refractometry
10. Sodium; serum
11. Transferase; aspartate amino (AST) (SGOT)
12. Urea nitrogen; quantitative

Components of the Blood Chemistry Panel

1. Glucose is a measure of the sugar content in the blood that is monitored to evaluate for diabetes or hypoglycemia. This test needs to be performed in a fasted state. Normal blood sugar should be between 70-110 mg/dl.
2. Urea Nitrogen (BUN) is a waste product of protein metabolism. It is produced in the liver and excreted by the kidneys. Normal values should be between 5-25 mg/dl. High values may occur when protein metabolism is not functioning properly.
3. Creatinine is a waste product of protein metabolism also. It represents the function of the kidneys. Normal serum concentration should be between 0.7-1.3 mg/dl.
4. Iron is the most sensitive indicator of iron stores (in the absence of liver disease or inflammation). Low values may represent certain types of anemia and should be evaluated by a physician.
5. Calcium is involved in many physiologic processes. A normal blood calcium level is essential for normal function of the heart, nerves, and muscles. It is also involved in the coagulation process.
6. Phosphorus is an essential element in the diet. It is a major component of the mineral phase of bone and occurs in all tissues, being involved in almost all metabolic processes. Calcium is controlled by the kidneys and parathyroid glands. Processing errors may affect this value.
7. Uric Acid is a constituent in the blood which transports nitrogen in the body. It is normally excreted in the urine to rid the body of nitrogen. Values that are high may indicate gout, arthritis or certain kidney problems. A low value is not clinically significant.
8. Sodium is an ion that is important in the conduction of nerves, contraction of muscles, and functioning of cells. It is controlled primarily by the kidneys and adrenal glands. Normal levels range between 137 to 147 mEq/L.
9. Potassium is important for muscles and nerves function. Potassium is controlled by the kidneys and is affected by diuretics or cardiovascular medications. Normal levels range between 3.5 to 4.8 mEq/L.
10. Chloride is an ion that is important in the functioning of cells as are sodium and potassium. It is primarily controlled by the kidneys and adrenal glands. Normal levels range between 98 to 105 mEq/L.
11. Total Protein is the total amount of protein circulating in the blood. This value represents general nutritional habits. Normal levels range between 6.3 to 7.9 g/dl.
12. Albumin is a carbohydrate-free plasma protein which transports fatty acids, bilirubin, and poorly saturated hormones. It also serves as a reserve store of protein. Normal levels range between 3.5 to 5.0 g/dl.
13. Globulin is a protein fraction. Elevated values may indicate chronic infections.
14. A/G Ratio is a ratio between Albumin and Globulin. Provided Albumin and Globulin values are normal, a high or low ratio is not significant.
15. Total Bilirubin is a bile pigment. It normally circulates in the plasma and is taken up by liver cells. High levels of bilirubin may result in jaundice.
16. LDH stands for lactate dehydrogenase. It is an enzyme involved in the breakdown of lactic acid. Anything which causes cellular damage, including heart attacks, liver disease, and blood drawing itself, may cause higher values.
17. Alkaline Phosphatase is an enzyme found primarily in bones and the liver. Values for pregnant women may be elevated.
18. SGOT stands for serum glutamic oxaloacetic transaminase. SGOT is a liver enzyme involved in cellular functions of the heart muscle and liver. Alcohol consumption, liver disease, and other normal factors may increase the value.
19. SGPT stands for serum glutamic pyruvic transaminase. SGPT, like SGOT, is an enzyme involved in the functions of heart, liver, and muscle cells. Alcohol consumption has been shown to increase this value.
20. GGT stands for Gamma Glutamyl Transpeptidase. Similar to SGOT and SGPT, GGT is an enzyme involved in the function of the liver, heart, and muscle cells. Alcohol consumption, liver disease, heart attacks, recent heavy physical exertion, and other normal factors have been shown to raise this value.
21. Cholesterol is used to make essential body substances, such as cell walls and hormones. High levels of cholesterol have been associated with an increased risk for heart disease. Low levels of cholesterol are preferred. Normal levels range between 150 to 220 mg/dl.
22. Triglycerides are blood fats that are the usual storage form of lipids in the body. This value can be affected by a recent meal or recent physical activity. An eight hour fast with no significant activity is required for accurate results.
23. HDL Cholesterol is a High Density Lipoprotein, and is commonly referred to as the "good” cholesterol. HDL Cholesterol is a transport protein that carries cholesterol away from the artery walls for removal from the body. The higher the HDL value, the lower the risk of cardiovascular disease. Exercise and weight loss have been shown to increase the HDL level, while smoking has been shown to decrease it.
24. LDL Cholesterol is a Low Density Lipoprotein, and is commonly referred to as the "bad" cholesterol. LDL Cholesterol, like HDL Cholesterol, is a transport protein. However, LDL transports cholesterol to the arteries. The lower the LDL Cholesterol concentration, the lower the risk of cardiovascular disease. A low-fat, low-cholesterol diet has been shown to decrease this value.
25. Cholesterol/HDL Ratio is a ratio of Total Cholesterol to HDL Cholesterol. This ratio has been shown to be a good predictor of cardiovascular disease risk, with the lower the ratio the better. A combination of regular aerobic exercise and good nutritional practices have been shown to improve this ratio.

(Please note that many books have differing numbers for normal values. The above values have been taken from Robert Wilkins book "Clinical Assessment in Respiratory Care")

Complete Blood Count

The Complete Blood Count (CBC) is one of the most routinely performed laboratory tests used for obtaining information about the patient's blood. The test is usually called a CBC with differential (used to determine the different types of white blood cells). The CBC with differential is a very common test that is done to find out if a person is anemic, has an infection, or may have a tendency to bleed.

The CBC examines three major types of cells; red blood cells (RBCs), white blood cells (WBCs), and platelets. The CBC involves counting the number of red cells and white cells in the blood, evaluating the red cell factors according to the size and hemoglobin content of the cells, and examining the cells visually. The CBC test consist of:

1. Red blood cell count (RBC)
2. Hemoglobin (Hb)
3. Hematocrit (Hct)
4. Erythrocyte index - Mean cell volume (MCV), Mean cell hemoglobin (MCH), and the Mean cell hemoglobin concentration (MCHC)
5. White blood cell count (WBC) and the differential of the white blood cells - Platelet count

Red blood cells (RBCs) are produced in the bone marrow by the maturation of nucleated cells known as normoblasts. The basic function of the RBC is to serve as a transport for hemoglobin, the protein that carries oxygen to the tissues. The RBC circulates for 120 days in the blood stream before being destroyed in the body's reticuloendothelial system.

Examination of the red blood cell is done by:

1. Red Cell Count (or Erythrocyte count) refers to the number of red blood cells. A machine known as a Coulter Counter usually does this electronically. The result of the test is expressed as number of cells per unit volume, specifically cells/µL. A typical laboratory normal range is 4.2 - 5.4 x 106/mm3 for females; for adult males it is 4.6 - 6.2 x 106 /mm3.
2. Hemoglobin (Hgb) is a protein in the RBC that is responsible for carrying oxygen to the tissues. It is formed in the bone marrow. The normal range for hemoglobin is highly age and sex-dependent, with men having higher values than women, and adults having higher values than children (except for neonates which have the highest values of all). Hemoglobin results are traditionally expressed as unit mass per volume, specifically grams per deciliter (g/dL). Typical lab values for a young adult female will range between 12 - 15 g/dL; for adult males it is 13.5 - 16.5 g/dL.
3. Hematocrit (Hct) - (also called the packed cell volume or PCV) is the volume or percentage of red blood cells in whole blood. The hematocrit is a measure of the total volume of the erythrocytes relative to the total volume of whole blood in a sample. The result is usually expressed as a percentage. The normal range is 38-47% for females, and 40-54% for males.
4. MCV stands for mean corpuscular volume. This is the mean volume of all the erythrocytes counted in the sample. The value is traditionally expressed in cuµ. The normal range is 80 - 96 cuµ in the adult. The formula for the calculation in general terms is MCV = hematocrit ÷ RBC count.
5. MCH stands for mean cell hemoglobin. This is a measure of the amount of hemoglobin associated with each red cell. The MCH represents the mean mass of hemoglobin in the RBC and is expressed in the mass unit, picograms. The value is determined by the formula, MCH (in pg) = (hemoglobin [in g/dL] x 10 ÷ (rbc count [in millions/µL]). Normal values will run between 27-31 pg. The MCH tends to be similar to that of the MCV and adds very little information.
6. MCHC stands for mean cell hemoglobin concentration. This value represents the mean hemoglobin concentration in each red blood cell. The MCHC is roughly twice the value for hemoglobin in whole blood and is expressed in the same units. The normal range is 32 - 36 g/dL. The value is calculated using the formula, MCHC [in g/dL] = hemoglobin [in g/dL] ÷ hematocrit [in L/L]
7. Platelet Count refers to the disk shaped structures found in the blood that have an important function in the coagulation process. The normal platelet count is between 150,000 and 400,000 mm3. Abnormal bleeding generally occurs when the platelet count drops below 50,000 mm3, if the platelets are functioning properly. Bleeding that results from decreased platelets usually results in small skin hemorrhages or as the oozing of blood from mucosal surfaces. Screening for proper platelet function is accomplished by use of the bleeding time test.

Disorders in the red blood cell count will revolve around either not enough red blood cells in the blood or too many red blood cells. The first is called anemia and the second is called polycythemia. Anemia is a decrease in the red blood cell count, hemoglobin, and hematocrit. It may be caused by blood loss, decreased red blood cell production, or an accelerated red blood cell breakdown.

In children, one of the most common causes of anemia is the result of iron deficiency caused by the lack of iron in the child's diet. Other nutritional anemias, such as deficiencies of vitamin B-12 or folic acid, are not very common. Another type of anemia is the result of problems in manufacturing hemoglobin (such as in sickle cell anemia or thalassemia). Other rare causes in a low red blood cell count involve patients who have leukemia or have an abnormality in their bone marrow. Uncommon conditions that lead to a premature breakdown of red blood cells, such as spherocytosis or systemic lupus, can also lead to a low red blood cell count.

Polycythemia is a condition in which there is an increase in the red blood cell count, hemoglobin, and hematocrit. Polycythemia can be classified as either primary or secondary. Secondary polycythemia is commonly seen in patients who have chronic obstructive lung disease. Because the patient with COPD lives with chronic hypoxemia, the bone marrow is stimulated to produce more red blood cells to help compensate for the lack of oxygen.

Primary polycythemia is caused by an uncontrolled proliferation of hematopoietic cells within the bone marrow called polycythemia vera. Although both types of polycythemia help increase the oxygen-carrying capacity of the blood, the condition often places stress on the heart and circulation. This is due to the increase in the viscosity or thickness of the blood, which increases the workload on the heart.

White Blood Cell (WBC) Count

The white blood cell (WBC) count indicates how many white blood cells are found in a microliter of whole blood. Strenuous exercise, digestion of a meal, daily stress, or the presence of disease can cause the WBC count to fluctuate by as much as 2000 daily. As a diagnostic tool, WBCs are only useful when analyzed along with the patient’s overall health status and the white cell differential.

The purposes of WBC Counts are to:

• Identify the existence of infections or inflammation.
• Determine whether further diagnostic tests (such as the WBC differential or bone marrow biopsy) are needed.
• Monitor the patient’s response to chemo- or radiation therapy.

Values: The WBC count can range from 4100 to 10900/microliter.

Interpretation

• Elevated WBC counts generally signal the presence an infection (i.e., an abscess, meningitis, appendicitis, or tonsillitis). Elevated WBCs can also be caused by leukemia or tissue necrosis caused by burns, myocardial infarction, or gangrene.
• Low WBC counts generally indicate bone marrow depression resulting from viral infections or toxic reactions.

Interfering Factors

• If the blood sample is excessively jostled or agitated it can cause hemolysis, interfering with the accuracy of the test results.
• If the patient exercises excessively, is stressed, or is digesting a meal when the count is taken, it can raise the WBC count, skewing the accuracy of the results.
• Some medications can cause the WBC to drop, resulting in inaccurate results.

White Blood Cell (WBC) Differential

The WBC differential (relative number of each type of white cell in the blood) includes information regarding white blood cell morphology and distribution. It yields more specific data regarding the immune function than the WBC counts.
The purposes of the WBC differential are to:

• Evaluate immune capacity regarding infections
• Detect presence of leukemia
• Determine severity and status of infections
• Detect and evaluate allergic reactions

Values and Interpretation

Relative and absolute values are both important in evaluating the WBC differential. For example, a patient who has a seemingly high lymphocyte count might actually be well within the normal range, depending on his white cell count.

Hemoglobin (HGB), Total

This test evaluates the amount of hemoglobin found in a deciliter (100 ml) of whole blood. The purpose of HGB Total tests are to help calculate MCH, mean corpuscular hemoglobin concentrations, the severity of anemia or polycythernia, and assist monitoring of the patient’s subsequent response to therapy.

Values and Interpretation
Concentration levels of hemoglobin can vary based on the patient’s age and sex, and type of blood sample drawn for testing. Low concentrations can be an indication of recent hemorrhages, anemia, or excessive retention of fluids. Elevated concentrations can indicate hemoconcentration from polycythemia or dehydration.

Hemoglobin Derivatives

Subsequent to the onset of signs of toxicity (i.e., anoxia and cyanosis), this test is used to calculate the percentage of total hemoglobin-containing abnormal derivatives such as: carboxyhemoglobin, sulfhemoglobin, and methemoglobin. Normal concentrations include:

• Carboxyhemoglobin = 3% of the total hemoglobin (up to 15% in tobacco smokers)
• Methemoglobin = less than 3%
• Sulfhemoglobin = undetectable

Hematocrit (Hct)

The percentage (by volume) of packed red blood cells (RBCs) in a whole blood sample is measured by the Hct. Centrifugation of anticoagulated whole blood in a capillary tube causes the packing. The number of RBCs and the average size of the RBC affect hematocrit levels. Hct test results are utilized to calculate two erythrocyte indices: mean corpuscular volume (MCV), and mean corpuscular hemoglobin concentration (MCHC).

The purposes of Hct tests include:

• Facilitating diagnosis of hydration, polycythemia, and anemia
• Calculating red cell indices
• Monitoring fluid imbalance, blood loss and replacement
• Performing screening when evaluating the complete blood count

Values and Interpretation

Factors affecting Hct values include: type of blood sample taken, patient’s sex and age, type of sample, and competency of the lab conducting the test. Reference values range from 40% to 54% for men, and 37% to 47% for women. Low Hct can result from anemia or hemodilution, while high Hct is suggestive of polycythemia or hemoconcentration.

Glucose, Fasting Blood Sugar (FBS)

The FBS test measures plasma glucose levels following a 12 to 14 hour fast. It is the test most often used to screen for diabetes mellitus. The purposes of FBS tests are:

• Screening for diabetes mellitus and other glucose metabolism disorders
• Monitoring drug or dietary therapy in diabetic patients
• Determining the insulin requirements in patients with uncontrolled diabetes mellitus, and those requiring parenteral or enteral nutritional support
• Evaluating patients with hypoglycemia

Values and Interpretation

While the normal range for FBS tests can vary depending on the particular lab procedure used, normal values after an 8-12 hour fast generally are:

• Fasting serum = 70 to 100 mg/dl or (3.9 to 5.6 mmol/L).
• Fasting whole blood = 60 to 100 mg/dl or (3.3 to 5.6 mmol/L).
• Nonfasting = 85 to 125 mg/dl or (4.7 to 6.9 mmol/L).
• In patients with an average age 50 to 70 to 115 mg/dl or (3.9 to 6.4 mmol/dl) in persons under age 50.

If fasting blood glucose levels at or higher than 140 to 150 mg/dl (7.8 to 8.3 mmol/L) or higher are measured on two or more occasions, the patient may be considered to be diabetic if other causes of hyperglycemia have been ruled out. Nonfasting levels higher than 200 mg/dl (11. 1 mmol/L) are also suggestive of diabetes. Pancreatitis, recent acute illness (such as myocardial infarction), Cushing’s syndrome, pituitary adenoma, hyperthyroidism, chronic hepatic disease, and pheochromocytoma can also cause elevated fasting blood glucose levels.

Depressed glucose levels can be caused by: hyperinsulinism, insulinoma, von Gierke’s disease, functional or reactive hypoglycemia, hypothyroidism, adrenal insufficiency, congenital adrenal hyperplasia, hypopituitarism, islet cell carcinoma of the pancreas, hepatic necrosis, and glycogen storage disease.

While not necessarily considered “laboratory data”, the skin test for tuberculosis can sometimes be an important aspect of patient assessment.

Interpretation of Tuberculin Skin Test and Treatment of Latent Tuberculosis Infection(LTBI)

Reaction to the Intermediate Strength PPD(mm induration at 48-72 hours) Category Clinical Groups Recommendation
>or = 5mm Positive · Known or suspected HIV infection · Close contacts of active TB cases · Chest X-ray suggests old, inactive TB · Persons with organ transplants or other immunosuppressed patients Treat for LTBI
>Or = 10 mm Positive · IV Drug · Diabetes, renal failure, blood malignancies, and certain other medical conditions · Immigrants from high prevalence areas · Residents and employees of high congregate settings · Mycobacteriology laboratory personnel · Children < 4 or children and adolescents exposed to adults in high risk categories Treat for LTBI
> Or = 15 mm Positive Positive with no risk factors Treat for LTBI

Recent Converters
INCREASE IN REACTION SIZE OVER 2 YEARS Age Recommendation
> Or = 10mm All Treat for LTBI

High Risk Individuals with Negative Skin Tests
Group Recommendation
HIV infected with skin test anergy Treat for LTBI
High risk contacts of active TB cases Treat for LTBI

The following is a brief introduction to electrocardiograms and their interpretation:

1. P wave = depolarization of the atria.
   QRS = depolarization of the ventricle.
   T wave = repolarization of the ventricle.
   
2. Cardiac muscle cells depolarize with a positive wave of depolarization, then repolarize to a negative charge intracellularly.
3. Skin "leads" or electrodes have a positive and negative end.
4. A positive wave form (QRS mainly above the baseline) results from the wave of depolarization moving toward the positive end of the lead. A negative waveform (QRS mainly below the baseline) is when a wave of depolarization is moving away from the positive electrode (toward the negative end of the lead).
5. ECG paper has 1 millimeter small squares - so height and depth of wave is measured in millimeters.
   10 mm = 1.0 mVolt
6. Horizontal axis is time.
   .04 seconds for 1 mm (1 small box).
   .2 seconds for 1 large box = 5 small boxes = 5 x .04 seconds.
   Positive QRS in Lead I.
   Negative QRS in Lead aVR.
   R wave = 7-8 mm high in Lead I.
   QRS wave = .06 seconds long in Lead I.
7. Lead nomenclature.

   Limb Leads	Chest Leads	Rhythm Strip
   I, II, IIIaVR, aVF, aVL	V1 - V6	Located on the bottom of the ECG printout. Selected to give the best relationship of the P wave to the QRS.

   
   
8. 
   
   
9. ECG interpretation: look at five areas, in order, on each ECG.
   

   Rate

   Rhythm (Intervals)

   Axis

   Hypertrophy

   Infarct

   
   . Rate
   Rate is cycles or beats per minute.
   Normal rate for the SA node 60-100.
   <60 bradycardia >100 tachycardia

SA node is the usual pacemaker, other potential pacemakers (if SA node fails) are atrial pacemakers with inherent rates of 60-80, AV node (rate 40-60), or ventricular pacer (rate 20-40). In certain pathologic conditions ectopic (out of place) pacemakers can go much faster at rates 150-250 cycles/minute. There are three methods of calculating rate:

1. Most Common Method:
   (Most rates can be calculated this way). Find an R wave on a heavy line (large box) count off "300, 150, 100, 75, 60, 50" for each large box you land on until you reach the next R wave. Estimate the rate if the second R wave doesn't fall on a heavy black line.

   Rate calculation

   Memorize the number sequence:

   300, 150, 100, 75, 60, 50

   
   
2. 
   
   
3. Mathematical method:
   Use this method if there is a regular bradycardia, i.e. - rate < 50. If the distance between the two R waves is too long to use the common method, use the approach: 300/[# large boxes between two R waves].
   
   
4. Six-second method:
   Count off 30 large boxes = 6 seconds (remember 1 large box = 0.2 seconds, so 30 large boxes = 6 seconds). Then, count the number of R-R intervals in six seconds and multiply by 10. This is the number of beats per minute. This is most useful if you have an irregular rhythm (like atrial fibrillation) when you want to know an average rate.
   

Rhythm (to include intervals)

The basic "core" of rhythms and measured "intervals" (PR, QRS, QT). Rhythms are often the most challenging aspect of ECG's..

Now for some basics - "arrhythmia" means abnormal rhythm.

The normal conduction pathway is: SA node --> AV node --> Bundle of HIS --> Bundle Branches.

Arrhythmia can be understood by realizing the existence of ectopic (out of place) foci (pacemakers) and understanding the normal conduction pathway of the heart. Very simply put, if the beat originates in the atria or AV node (supraventricular) the QRS is usually narrow (normal), because it comes from above along the normal pathway.

If the beat is ventricular in origin, the QRS is wide and bizarre because it doesn't come down the normal pathway.

Aberrance is an exception to this rule. Here it does actually follow the normal pathway (atria - AV node - ventricle), but for some reason the pathway is refractory to the beat and you get a wide QRS.

A reasonable way to group arrhythmias is in four general groups. Let us briefly review these four groups. Then we will develop some common sense principles for evaluating rhythm (to include intervals).

Axis

Direction of depolarization (vector) of the QRS complex.

1. The left ventricle is thicker so the mean QRS vector is down and to the left. (The origin of the vector is the AV node with the left ventricle being down and to the left of this).
2. The vector will point toward hypertrophy (thickened wall) and away from the infarct (electrically dead area).

Since lead I and aVF are perpendicular to each other, you can use those two leads to quickly determine axis.
Lead I runs from right to left across a patient's body, positive at the left hand: (See figure 28).

If the QRS in lead I is positive (mainly above the baseline), the direction of depolarization will be in the positive half (right half) of the circle above. You can make a diagram and shade in the positive half of the circle.

Lead aVF runs from top to bottom across a patient's body, positive at the feet:

If the QRS in lead AVF is positive (mainly above the baseline), the direction of depolarization will be in the positive half (lower half) of the circle above. You can make a diagram and shade in the positive half of the circle:

To find the axis, overlap the two circles. The common shaded area is the quadrant in which the axis lies. In this example, the axis lies in the normal quadrant, which on a patient, points down and to the left.

You can repeat this process for any two leads, but I and AVF are the classic places to look. If you realize that there are two leads to consider and a positive (+) or (-) orientation for each lead, there would be four possible combinations. Memorize the following axis guidelines.

The bottom line is: if the axis is shifted out of the normal quadrant, evaluate the reasons for this.

Hypertrophy

Hypertrophy criteria are fairly straightforward: we will be looking for enlargement of any of the four chambers.

1. LVH: (Left ventricular hypertrophy). Add the larger S wave of V1 or V2 (not both), measure in mm, to the larger R wave of V5 or V6. If the sum is > 35mm, it meets "voltage criteria" for LVH. Also consider if R wave is > 12mm in aVL. LVH is more likely with a "strain pattern" which is asymmetric T wave inversion in those leads showing LVH.
2. RVH: (Right ventricular hypertrophy). R wave > S wave in V1 and R wave decreases from V1 to V6.
3. Atrial hypertrophy: (leads II and V1). Right atrial hypertrophy - Peaked P wave in lead II > 2.5mm amplitude. V1 has increase in the initial positive deflection. Left atrial hypertrophy - Notched wide (> 3mm) P wave in lead II. V1 has increase in the terminal negative deflection.
   
   

Infarct

Accurate ECG interpretation in a patient with chest pain is critical. Basically, there can be three types of problems - ischemia is a relative lack of blood supply (not yet an infarct), injury is acute damage occurring right now, and finally, infarct is an area of dead myocardium. It is important to realize that certain leads represent certain areas of the left ventricle. By noting which leads are involved, you can localize the process. The prognosis often varies depending on which area of the left ventricle is involved (i.e. anterior wall myocardial infarct generally has a worse prognosis than an inferior wall infarct).

V1-V2            anteroseptal wall
V3-V4            anterior wall
V5-V6            anterolateral wall
II, III, aVF      inferior wall
I, aVL            lateral wall
V1-V2            posterior wall (reciprocal)

For the posterior wall, remember that vectors representing depolarization of the anterior and posterior portion of the left ventricle are in opposite directions. So, a posterior process shows up as opposite of an anterior process in V1. Instead of a Q wave and ST elevation, you get an R wave and ST depression in V1.

Two other caveats: One is that normally the R wave gets larger as you go to V1 to V6. If there is no R wave "progression" from V1 to V6 this can also mean infarct. The second caveat is that, with a left bundle branch block, you cannot evaluate "infarct" on that ECG. In a patient with chest pain and left bundle branch block, you must rely on cardiac enzymes (blood tests) and the history.

Fascicular Blocks

Fascicular blocks are blocks of part of the left bundle, either the posterior or anterior division:

Anterior fascicular block - the most common.

You will see left axis deviation (-30 to -90) and a small Q wave in lead I and an S in lead III (Q1S3). The QRS will be slightly prolonged (0.1 - 0.12 sec).

Posterior fascicular block - less common.

You will see right axis deviation, an S in lead I and an Q in lead III (S1Q3). The QRS will be slightly prolonged (0.1 - 0.12 sec).

Bifascicular block.

This means two (2) of the three (3) fascicles (in diagram) are blocked. The most important example is a right bundle branch block and a left anterior fascicular block. Watch out for this. Only one fascicle is left for conduction, and if that fascicle is intermittently blocked, the dangerous Mobitz 2 is set up!

"Fascicular Blocks" may seem a bit complicated - simply remember that axis deviation is the clue. In your differential, consider posterior fascicular blocks with right axis deviation and consider anterior fascicular blocks with left axis deviation. Fascicular blocks cause axis deviations, like infarcts and hypertrophy. If you see a left or right axis deviation, first look for infarct or hypertrophy. If neither is present, the remaining diagnosis of fascicular block is usually correct. Review differential diagnosis of right and left axis deviation.

Suggestions/Summary

1. Look at each ECG for rate, rhythm, axis, hypertrophy, and infarct. The systematic interpretation guidelines below will serve as a quick reference

INTERPRETATION GUIDELINES for Electrocardiograms

RATE
Rate calculation
Common method: 300-150-100-75-60-50
Mathematical method: 300/# large boxes between R waves
Six-second method: # R-R intervals x10

RHYTHM
Rhythm Guidelines:
1. Check the bottom rhythm strip for regularity, i.e. - regular, regularly irregular, and irregularly irregular.
2. Check for a P wave before each QRS, QRS after each P.
3. Check PR interval (for AV blocks) and QRS (for bundle branch blocks). Check for prolonged QT.
4. Recognize "patterns" such as atrial fibrillation, PVC's, PAC's, escape beats, ventricular tachycardia, paroxysmal atrial tachycardia, AV blocks and bundle branch blocks.

AXIS

Left axis deviation differential: LVH, left anterior fascicular block, inferior wall MI.
Right axis deviation differential: RVH, left posterior fascicular block, lateral wall MI.

HYPERTROPHY

1. LVH -- left ventricular hypertrophy = S wave in V1 or V2 + R wave in V5 or V6 > 35mm or aVL R wave > 12mm.
2. RVH -- right ventricular hypertrophy = R wave > S wave in V1 and gets progressively smaller to left V1-V6 (normally, R wave increases from V1-V6).
3. Atrial hypertrophy (leads II and V1)
   Right atrial hypertrophy -- Peaked P wave in lead II > 2.5 mm in amplitude. V1 has increase in the initial positive direction.
4. Left atrial hypertrophy -- Notched wide (> 3mm) P wave in II. V1 has increase in the terminal negative direction.

INFARCT

Certain leads represent certain areas of the left ventricle:
V1-V2          anteroseptal wall II, III, aVF inferior wall
V3-V4          anterior wall I, aVL lateral wall
V5-V6          anterolateral wall V1-V2 posterior wall (reciprocal)

A
Acidemia - abnormally high level of acid in the blood, low pH (< 7.35)
Acidosis - condition resulting from accumulation of acid in the blood and tissues
Acute - In medical language, relatively brief in time. Example, a cold or flu is an acute illness.
Acute Interstitial Pneumonia (AIP) - Formerly called Hamman-Rich Syndrome (or disease), AIP has been redefined as a specific idiopathic interstitial pneumonia
Adult Respiratory Distress Syndrome (ARDS) - respiratory failure of sudden onset characterized by leakage of plasma into the lungs via damaged capillaries, resulting in fluid accumulation which deprives the lungs of their ability to expand. ARDS is a medical emergency. [ARDS Support Center website]
Air sacs - see Alveoli
Air trapping - the air caught behind collapsed bronchial branches during expiration
Airway - a passageway for air into or out of the lungs.
Airway Collapse - Actual collapse or closure of branches of the bronchial tree, caused by weakened bronchial walls secondary to disease.
All Trans Retinoic Acid (ATRA) - Vitamin A derivative being investigated for possible tissue regeneration in patients with mild to moderate emphysema. ATRA is known to be toxic when used systemically, but its use in treating acute promyelocytic leukemia (APL) has shown promising results (see ATRA Syndrome)
Alkalemia - a blood pH above normal (> 7.45).
Alpha1 Antitrypsin Deficiency (A1AD) - an inherited recessive disorder resulting in low or no production of Alpha1 Antitrypsin. Lack of this protein leads to organ damage, mainly to the liver and lung. [Alpha1 Assn]
Alveolar Macrophage (AM) - A cell in the lungs which engulfs bacteria and foreign material and produces enzymes to protect the lung.
Alveoli (pl) (singular: alveolus) - tiny air sacs at the end of the bronchioles where oxygen crosses capillaries into the bloodstream, exchanging it for carbon dioxide crossing from the bloodstream into the alveoli to be exhaled. Adults have roughly 300 million microscopic alveoli in their lungs
Antibiotic - medication that interferes with the growth of bacteria and may stop an infection.
Anti-inflammatory - a drug used to fight inflammation
Apnea - the absence of spontaneous respiration
Arterial Blood Gases (ABG) - a lab test of arterial blood (usually taken from the wrist) which measures carbon dioxide and oxygen levels as well as acid-base status.
Normal ABG values: pH 7.32 to 7.45
PO2 80 to 98 mmHg
PCO2 35 to 45 mmHg
SaO2 96 to 98%
SaO2 of 90% or above is considered adequate to support tissues and body functions. At less than 90% tissues and organs begin to suffer and supplemental oxygen may be prescribed.
Artery - one of the tubular branching vessels that carry blood from the heart to the organs and parts of the body; arteries usually carry oxygenated blood.
Asthma - a chronic inflammatory airway disease characterized by airway narrowing, bronchospasm and wheezing; asthma is considered a reversible condition. Asthma is often called a reactive airway disease when it's expected to be of short duration, i.e. 'outgrown' as a child ages.
Asthmatic Bronchitis - Coexistence of wheezing and chronic bronchitis.
Atelectasis - incomplete expansion of the lung
ATRA - See All Trans Retinoic Acid
ATRA Syndrome - a life-threatening complication that can occur during the treatment of acute promyelocytic leukemia (APL) by ATRA. Main clinical signs are respiratory distress, fever, pulmonary infiltrates, weight gain, pleural effusion, renal failure, pericardial effusion, cardiac failure and hypotension.

B
Bacteria - single-celled organisms which cause infections; they are usually treated with antibiotics.
Barrel chest - the shape of the chest in some patients with COPD when air trapping causes over-inflated lungs
BiPAP - Bi-Level Positive Airway Pressure - a machine which administers air under pressure via a nose mask to keep airways open and unobstructed. Respironics' (BiPAP®) units track the patient's breathing and lower the pressure during exhalation.
Blebs - Air-filled cysts near or on the surface of the lung. Blebs are less than 1cm in diameter. Compare to bullae
Blebs Disease - see Spontaneous Pneumonothorax
Blood Pressure (BP) - force exerted by the blood on the walls of the main arteries of the body. BP measurements are made both when the heart's ventricles are contracting (systolic pressure), and when the ventricles are at rest (diastolic pressure). In a young adult, a healthy pressure averages 120 systolic and 80 diastolic (recorded as 120/80). Hypertension occurs when BP is too high; hypotension is too low a BP. [symptoms of hypotension]
Blue Bloater - term for the COPD patient whose symptoms include hypoxemia, secondary polycythemia, CO2 retention, pulmonary hypertension and cor pulmonale. Compare to Pink Puffer Term is rarely used anymore.
Body Box - see Plethysmography (THIS ONE'S FOR THE LIVING!!)
Bone Mineral Density (BMD) - bone density is the amount of bone tissue in a certain volume of bone. This measurement is taken using a special x-ray called quantitative computed tomogram
Bradypnea - decreased breathing rate, usually under ten breaths per minute. Bradypnea is often caused by the administration of narcotic analgesics such as morphine.
Bronchi (pl) (singular: bronchus) - branches of the bronchial tree
Bronchial tree - term used to describe the ductwork of the respiratory system which branch like a tree, the terminal 'branches' leading to the alveoli.
Bronchiectasis - a chronic inflammatory or degenerative condition of bronchi or bronchioles marked by dilation and loss of elasticity of the walls.
Bronchioles - tiniest branches of the bronchial tree, they lead into the alveoli
Bronchiolitis Obliterans (BO) - an obstructive process involving small airways in the lung periphery. It may occur following a bout of pneumonia or lung transplantation.
Bronchiolitis Obliterans Organizing Pneumonia (BOOP) - obstructive condition characterized by granulation tissue plugs within the small airways. This abnormal tissue extends into alveolar ducts and alveoli.
Bronchitis - acute or chronic inflammation of the bronchial airways or any part of them.
Acute Bronchitis - inflammation of cells lining the bronchi causes production of yellow or gray mucus which clogs airways resulting in shortness of breath, wheezing and pain in upper chest, especially when coughing.
Chronic Bronchitis - to be considered chronic, there must be a productive cough on most days for at least three months of the year, for at least two consecutive years.
Bronchoalveolar Lavage (BAL) - during bronchoscopy, a small amount of saline is injected into the distal (far) portions of the lung, then aspirated back through the bronchoscope, washing out the alveoli. The material recovered is then analyzed for cell count, differential or foreign bodies.
Bronchodilator - a drug that relaxes the smooth muscles in the constricted airway.
Bronchoscopy - a procedure where a lighted bronchoscope is inserted through the nose or throat to allow visual examination of the trachea, bronchi and select bronchioles.
Broncopulmonary Dysplasia (BPD) - abnormal development of the lung that results from oxygen toxicity in premature infants who receive prolonged respiratory assistance for hyaline membrane disease.
Bronchospasm - constriction of air passages of the lung by spasmodic contraction of the bronchial muscles, obstructing the flow of air.
Bullae (pl) (singular: bulla) - large air spaces within the lung, >1-2 cm in diameter, formed by ruptured alveoli. Compare to blebs.
Bullous Disease - See Vanishing Lung - also known as type 1 bullous disease and primary bullous disease of the lung

C
Carbon Dioxide (CO2) - a colorless, odorless, nonflammable gas produced in respiration, and given off by the tissues to the blood, to be exhaled by the lungs in exchange for oxygen.
Cardiopulmonary (C/P) - pertaining to both heart and lungs
Chest X-Ray (CXR) - images of the chest cavity can be used to assess lung disease. Dense structures of the body, like bone, will appear white; air will be indicated by areas in black ('air' is a void which can't be photographed). All other structures will appear as shades of gray.
Chronic - refers to a disease or disorder that shows little change in symptoms from day to day, but implies a continuing disease process with progressive deterioration.
Chronic Lung Disease (CLD) - broad term covering both obstructive conditions, characterized by a slow rate of forced expiration, and restrictive disease characterized by a reduction in total lung capacity.
Chronic Obstructive Pulmonary Disease (COPD) - COPD is diagnosed when chronic bronchitis and emphysema present themselves as one disease, most often in smokers and former smokers. The definition of COPD recognized by both the American Thoracic Society and the European Respiratory Society is a disorder characterized by reduced maximal expiratory flow and slow forced emptying of the lungs; features that do not change markedly over several months. This airflow limitation is only minimally reversible with bronchodilators.
Cilia (pl) - tiny hairlike cells that line the airways and beat constantly toward the pharynx to assist in removal of mucus and dust particles.
Clubbing - refers to a condition where tips of the fingers enlarge and the nails become curved from front to back as a result of chronic low blood-oxygen levels.
Clubbing has 'reversed' in patients who underwent lung transplantation.
Compliance (Patient compliance) - in medical language, the practice of following medical direction fully and correctly.
Computerized Axial Tomography Scan (CAT or CT) - An x-ray procedure that uses a computer to produce a series of three dimensional images of the body and it's organs.
Congestive Heart Failure (CHF) - failure of the heart to maintain adequate blood circulation
Conserver - see Oxygen Conserver
Continuous Positive Airway Pressure (CPAP) - a machine which administers a continuous flow of air under pressure via a nose mask to keep airways open and unobstructed.
Cor Pulmonale - enlargement of the right ventricle resulting from pulmonary hypertension secondary to lung disorders
Corticosteroid - natural or synthetic hormones like those produced by the body's adrenal glands which are used to reduce swelling and inflammation
CPAP Titration (Test) - see Oximetry
Cyanosis - dusky bluish or purplish tinge to the skin caused by insufficient blood oxygen
Cystic Fibrosis (CF) - a disease of the mucus and sweat glands which causes disorders of the lungs and pancreas.
CF is the leading cause of chronic lung disease in children and young adults, and the most common fatal hereditary disorder affecting Caucasians in the US.

D
Demand Positive Airway Pressure (DPAP) - This machine monitors breathing. If spontaneous respiration doesn't occur within eight seconds, DPAP will provide the patient a 'breath' at whatever pressure flow necessary to move air into the lungs. Indications for DPAP usage is intolerable use of CPAP.
Desaturation - term commonly used to indicate decrease in oxygen saturation of hemoglobin.
Desquamative Interstitial Pneumonitis (DIP) - thought by some to be an early stage of idiopathic pulmonary fibrosis. This type of interstitial pneumonia occurs in current or past smokers
Diaphragm - a dome shaped muscle above the abdomen and below the lungs. When it contracts it creates negative pressure within the chest allowing air to be drawn into the lungs.
Diffuse Alveolar Disease (DAD) - See IPF
Diffusion - movement of oxygen or carbon dioxide across the membrane of the alveoli
Dyspnea - difficult or labored breathing; air hunger

E
Echocardiogram (ECHO) - a picture of the heart produced on a television screen by 'echoes' of ultrasound
Edema -an abnormal accumulation of fluid in connective tissue causing puffy swelling
Elastic recoil - ability of the lung to 'snap back' at the end of inspiration.
Electrocardiogram (ECG or EKG) - a record of the electrical activity of the heart; it records electrical impulses preceding contraction of the heart muscle.
Embolism - the sudden blocking of an artery by an embolus carried to the site by the blood flow.
Embolus - clot, or foreign material (such as a fat globule)
Emphysema - a chronic obstructive pulmonary disease characterized by dilation and destruction of alveoli leading to large air spaces, decreased elastic recoil and air trapping. Emphysema is one of two conditions which present as a singular disease called COPD; the other is chronic bronchitis.
Endotracheal Tube (ET) - a tube which by which a patient is connected to a respirator, it's inserted through the patient's mouth or nose, passes through the throat (and vocal cords), and into the air passages. The patient will be unable to speak while the tube is in place.
End-stage Emphysema - "End-stage refers to the patient for whom the damage to their lungs has reached a stage where symptoms severely affect their quality of life and has begun to affect other organs, such as the heart. Drugs, progressive exercise programs, oxygen, lung reduction surgery, and ultimately lung transplants are considered in a step-wise fashion to maximize the oxygen delivery from what lung tissue remains."
End-stage Organ Disease - a disease that ultimately leads to functional organ failure. Examples: emphysema (lungs), cardiomyopathy (heart), and polycystic kidney disease (kidneys).
Etiology - the cause or origin of a disease or disorder.
Eupnea - normal respiration; implies normal tidal volume, with respiratory rate (adults) about 14-18
Exacerbation - a period when a disease or medical condition becomes worse.
Expiration - breathing out; exhaling
Expiratory Reserve Volume (ERV) - maximal amount of air that can be expired starting at Functional Residual Capacity (FRC).
Extracorporeal Membrane Oxygenator (ECMO) - a device that acts as an artificial lung, oxygenating the blood that passes through it from the patient's blood vessels.
Exudate - the material composed of serum, fibrin and white blood cells in variable amounts that escapes from blood vessels into a superficial lesion

F
Fibrosis - a condition marked by relative increase in formation of interstitial fibrous tissue in any organ or region of the body (scar tissue is fibrous)
Flutter® - Brand name of a mucus clearing device
Forced Expiratory Flow (FEF) - a flow rate measurement of how much air can be expired from the lungs
Forced Expiratory Volume (FEV1) - the amount of air expelled the first second following maximal inspiration during the test for vital capacity
Forced Vital Capacity (FVC) - Forced vital capacity is the maximum volume of gas that can be expired forcefully after a maximum inspiration.
Functional Residual Capacity (FRC) - lung volume at the end of normal expiration.
At FRC, the tendency of the lungs to collapse is exactly balanced by the tendency of the chest wall to expand.

G
Gastroesophageal Reflux Disease (GERD) - flow of stomach contents back up into the esophagus.
Gunk - slang term for mucus.

H
Heart Rate (HR)- pulse; number of times the heart beats in one minute
Hypercapnia - an abnormally high carbon dioxide level in the blood (pCO2>45 mmHg)
Symptoms:
increased respiratory rate
headache
confusion
nausea and/or vomiting
lethargy
Hypertension - abnormally high blood pressure
Hyperventilate - to breathe abnormally fast and deep, resulting in excessive amounts of oxygen in the lungs and reduced carbon dioxide levels in the blood
Hypotension - abnormally low blood pressure
Symptoms:
lightheadedness
fainting
weak pulse
sweats
loss of circulation in the limbs
Hypoxemia - deficient oxygenation of the blood (PaO2 <55 mmHg or Sa02 <85%) [Hazards of hypoxemia: How to protect your patient from low oxygen levels CME Module]
Symptoms:
tachycardia is primary response
anxiety
agitation / mood changes
forgetfulness
inability to concentrate
altered levels of consciousness
pallor - skin may feel cool and clammy
Cyanosis is a late sign of hypoxemia
Hypoxia - deficiency of oxygen reaching tissues of the body

I
Idiopathic - of no known apparent cause or origin
Idiopathic Pulmonary Fibrosis (IPF) - Term for interstitial lung disease of unknown origin. Also called pulmonary fibrosis.
Immotile Cilia Syndrome (ICS) - Immotile Cilia Syndrome occurs when cilia in the body are unable to move. See PCD for more.
Immune System - a complex network of specialized cells and organs that protects the body against attack by "foreign invaders." When functioning properly it produces antibodies to fight off infections from bacteria, virus, fungi and other parasites.
Inflammation - redness, warmth and swelling in tissue following infection or injury; the immune system's protective reaction to an irritant. Chronic inflammation usually involves formation of new connective tissue. In COPD it can lead to airway obstruction; with ILD this causes a reduction in lung capacity.
Inhaler - the dispenser for metered-dose medications [Instructions for using an inhaler]
Inspiration - breathing in
Inspiratory Capacity (IC) - the maximal volume that can be inspired after a normal (non forced) expiration
Inspiratory Muscle Trainer (IMT) - a small device used to exercise and strengthen respiratory muscle endurance
Inspiratory Reserve Volume (IRV) - additional volume that can be inspired with maximum effort after a normal inspiration.
Interstitial - refers to tissue between alveoli of the lungs (called interstitium); outside the vascular system interstitial refers to the space in the tissues between cells
Interstitial Lung Disease (ILD) - term which includes more than 130 lung disorders characterized by fibrosing (scarring) in the lungs. A common link between various types of ILD is they all begin with an inflammation of known or unknown origin. Also called Pulmonary Fibrosis.
- Inflammation involving the bronchioles is called bronchiolitis
- Inflammation involving the alveoli (air sacs) is called alveolitis
- Inflammation involving the small blood vessels is called vasculitis.
When the cause of ILD is unknown, it's called "idiopathic" See pulmonary fibrosis for a partial list of terms which refer to interstitial lung disease.

K
Kartagener's Syndrome (KS) - a condition where the heart is located on the right side of the body in patients with Immotile Cilia Syndrome

L
LAM - See Lymphangioleiomyomatosis
Lung - one of a pair of breathing organs located within the chest which remove carbon dioxide from and bring oxygen to the blood.
Lung Transplant (TX or XP) - surgery to replace one or both diseased lungs with healthy ones from a human donor. [transplant links]
Lung Volume Reduction Surgery (LVRS) - Reduction Pneumoplasty is performed on patients with emphysema and chronic obstructive pulmonary disease (COPD). Varied surgical procedures allow the compressed lung to expand, thus establishing improved respiratory function. LVRS is also referred to as lung shaving, lung contouring, thoracoscopic bullectomy or simply lung reduction.
Lymphangioleiomyomatosis (LAM) - rare lung disease that affects only women; abnormal muscle cells invade the lung and airways, as well as blood and lymph vessels, causing them to become obstructed.
Lymphocytic Interstitial Pneumonia (LIP) - Lymphocytic interstitial pneumonia is a syndrome of fever, cough and dyspnea, with bibasilar pulmonary infiltrates consisting of dense interstitial accumulations of lymphocytes and plasma cells.

M
Magnetic Resonance Imaging (MRI) - a diagnostic technique which uses magnetic fields and radio waves to produce cross-sectional images of soft tissue without X-rays or other radiation.
Maintenance - continuing on a long-term basis, as in "maintenance therapy" or "rehab maintenance"
Metabolic Equivalent (MET) - the amount of oxygen required while sitting very quietly at rest (approximately 3.5 milliliters of oxygen per kilogram of body weight).
Metered Dose Inhaler (MDI) - device which dispenses a specific amount of medication in aerosol or powdered form
Mucus - slippery secretions that serve to moisten and protect the mucous membranes by special cells within the bronchial tree, usually as a result of irritation, inflammation or infection of the airways. (pretty synonymous with phlegm)

N
Nasal Cannula (NC) - a rubber or vinyl tube which extends around the user's face with curved prongs that fit into the nostrils for delivery of oxygen at low flow rates. Also referred to as "nose hose" (slang)
National Emphysema Treatment Trial (NETT) - a multicenter randomized trial comparing maximal medical therapy versus maximal medical therapy with LVRS in patients with moderate to severe emphysema to determine efficacy of this surgical procedure for the purpose of resuming Medicare reimbursement (which was halted in 1996).
Nebulizer - an atomizer device that sprays liquid medication in aerosol form into the air a patient breathes
Nose Hose - aka Nasal Cannula (NC)
Nuclear Scan (also called Ventilation Perfusion (VQ) Scan) - test using small amounts of radioactive material to compare left and right lung functions (blood flow and gas exchange)

O
Obstructive Sleep Apnea (OSA) - a common respiratory sleep disorder characterized by snoring and episodes of breathing cessation that causes blood oxygen levels to fall below acceptable levels.
Open Lung Biopsy (OLB) - a small piece of lung tissue is obtained for examination by surgical incision of the chest wall (thoracotomy) performed under general anesthesia by a Thoracic Surgeon.
Organic Dust Toxic Syndrome (ODTS) - a febrile illness occurring after heavy organic dust exposure; symptoms resemble those of acute farmer's lung.
Osteoporosis - weakening of bones by decrease in bone mass and mineral density, and enlargement of bone spaces producing fragility; caused by disturbances of nutrition and mineral metabolism. [CME module on Steroid-induced Osteoporosis ]
Oximeter - a noninvasive device for measuring continuously the estimated degree of oxygen saturation of the circulating blood. The oximeter 'clips' to a finger, toe, nose or ear lobe and is painless to use.
Oximetry - noninvasive measurement of the estimated level of arterial oxygenation in circulating blood; report usually includes baseline functional O2 saturation and heart rate, as well as lowest functional O2 saturation and heart rate during monitored activity (i.e. exercise, oxygen therapy)
Oxygen (O2) - colorless, odorless gas essential for all life processes; the most important component of air. See Hypoxemia for symptoms of insufficient oxygenation
Oxygen Conserver - device designed to maintain adequate oxygenation with a reduction in flow rate.
Oxygen debt - cumulative deficiency of oxygen that develops in the body during periods of intense activity and must be made good when the body activity returns to a normal level. In patients with severe pulmonary insufficiency, climbing a step or two can be considered 'intense activity'
Oxygen Therapy - use of supplemental oxygen to assure the body receives an amount sufficient to provide for its needs. (SaO2 of 90 or greater)
Oxygen Titration Test - see Oximetry

P
Pack Years - a measure of cigarette smoking over someone's lifetime, figured as the number of packs per day times the number of years a person has smoked. Ten pack-years could refer to a smoking history of two packs a day for five years, one pack/day for 10 years, or half a pack a day for 20 years. One "pack year" means 7300 cigarettes, or 1460 cigars, or 7.3kg of pipe tobacco.
Palliative - a therapy that relieves symptoms, such as pain, but does not alter the course of disease. Its primary purpose is to improve the quality of life (QOL).
Peak Expiratory Flow Rate (PEFR) - the fastest speed a person can expel air from the lungs after taking in as big a breath as possible
Peak Flow Meter (PFM) - small device used to measure a person's peak expiratory flow rate.
Perfusion - passage of blood through the lungs
Perfusion Scan - test to determine the status of blood flow to an organ.
Phlegm - thick, gluey, stringy mucus secreted in the respiratory passages usually as a result of inflammation, irritation or infection of the airways, and discharged through the mouth. (often synonymous with mucus, this word is no longer widely used)
Pink Puffer - term describing the COPD or emphysematic patient whose symptoms are breathlessness, hyperinflation, mild hypoxemia and a low PCO2 . Compare with Blue Bloater. Term is rarely used anymore.
Pleura - either of a pair of two-walled sacs of serous membrane that covers and protect the lung.
Pleural Cavity - the space between the two layers of pleura; the chest cavity
Pleural Space - the fluid-filled "space" between the two pleural walls (visceral and parietal pleura).
Pleurisy - inflammation of the pleura with or without diffusion of an exudate into the pleural cavity
Plethysmography or Body Box - an airtight chamber with clear doors where one sits to have lung volumes measured. Breathing is accomplished through a mouthpiece.
Pneumothorax (PTX)- presence of air in the pleural cavity, caused by rupture of the plural membrane or by trauma through the chest wall; often referred to as a collapsed lung. Compare to Spontaneous Pneumothorax
Pneumonoultramicroscopicsilicovolcanoconios - a lung disease caused by the inhalation of very fine silicate or quartz dust and occurring especially in miners.
This is the longest word in the English language. To pronounce it split into parts. Easy, no?
pneu mono ultra micro scopic silico volcano co niosis
Polycythemia - Too many red blood cells. The condition exists when the hemoglobin, red blood cell (RBC) count, and total RBC volume are all above normal. .
Positive Airway Pressure (PAP) - Positive airway pressure adjuncts are used to mobilize secretions and treat conditions such as atelectasis, or to keep airways open and unobstructed in patients with sleep apnea. They include continuous positive airway pressure (CPAP), positive expiratory pressure (PEP), expiratory positive airway pressure (EPAP). and bilevel positive airway pressure (BiPAP)
Positive End Expiratory Pressure (PEEP) - a method of mechanical ventilation in which pressure is maintained to increase the volume of gas remaining in the lung at the end of expiration, thus keeping alveoli open and improving gas exchange.
Positive Pressure Ventilation (PPV) - process of forcing gases down a patient's trachea using either a manual control technique or using an automatic ventilator. PPV can be done using a manual resuscitator or the rebreathing bag on the anesthesia machine; for long term use an automatic ventilator is usually prescribed.
Post Nasal Discharge (PND) - the sensation of mucus accumulation in the throat or a feeling that mucus is dripping downward from the back of the nose into the throat. Also called Post Nasal Drip
Primary Ciliary Dyskinesia (PCD) - condition where cilia in the body fail to beat effectively causing mucus to become trapped in various parts of the respiratory system.
PCD, Immotile Cilia Syndrome (ICS) and Kartagener's Syndrome (KS) refer to the same condition, with the exception that in KS the heart is located on the right side of the body.
Primary Immunodeficiency (PIDS) - Primary immune deficiency diseases are inherited disorders in which part of the body's immune system is missing or fails to function properly. Often presenting as 'common' infections or conditions (such as asthma or sinusitus), PIDs can go undetected for many years resulting in permanent damage to organs, and even the patient's death.
Ten warning signs of PIDS
- Eight of more new ear infections within one year,
- Two or more serious sinus infections within one year.
- Two or more months on antibiotics with little effect.
- Two or more pneumonias within one year.
- Failure of an infant to thrive (gain weight or normal growth).
- Recurrent deep skin or organ abscesses.
- Persistent thrush in mouth or elsewhere on skin, after age one.
- Need for intravenous antibiotics to clear infections.
- Two or more deep-seated infections such as osteomyelitis, cellulitis, or sepsis.
- A family history of primary immune deficiency.
Primary Pulmonary Hypertension (PPH) - see Pulmonary Hypertension
Productive Cough - a cough in which mucus or phlegm is dislodged, enabling a person to clear the lungs.
Puffers - slang term for aerosol metered dose inhalers
Pulmonary - pertaining to the lungs
Pulmonary Alveolar Proteinosis (PAP) -a rare condition characterized by a disturbance in surfactant turnover which causes the alveoli to fill with eosinophilic, proteinaceous material closely resembling surfactant. Treatment consists of bronchoalveolar lavages.
Pulmonary Artery (PA) - blood vessel that delivers oxygen-poor blood from the right ventricle to the lungs
Pulmonary Edema (PE) - condition (usually acute, but sometimes chronic) that occurs when too much fluid accumulates in the lungs, blocking transport of oxygen into the blood.
Pulmonary Embolism (PE) - the closure or narrowing of the pulmonary artery, or one of its branches, by an embolus.
Pulmonary Fibrosis (PF) - condition characterized by deposition of scar tissue in the lung.
Pulmonary Fibrosis by other names:
Acute Interstitial Pneumonitis
Chronic diffuse fibrosing
Chronic diffuse sclerosing
Chronic interstitial pneumonia
Cryptogenic fibrosing alveolitis
Diffuse idiopathic interstitial fibrosis
Diffuse idiopathic pulmonary fibrosis
Diffuse infiltrative pulmonary disease
Desquamative interstitial pneumonitis
Fibrosing alveolitis
Hamman-Rich Disease or Syndrome
Honeycomb lung
Honey lung
Idiopathic fibrosing alveolitis
Idiopathic interstitial fibrosis of lung syndrome
Shrinking Lung
Stiff Lung
Usual interstitial pneumonitis (UIP)

Pulmonary Function Tests (PFT) - set of tests to evaluate the mechanical properties of the lung by studying lung volumes and capacities (term often used interchangeably with spirometry) Quick Ref Evaluation of PFT's
Related terms:
TLC - Total Lung Capacity - volume of lungs following maximum voluntary inspiration
RV - Residual Volume - the amount of air left behind after a maximum expiratory effort
VT - Tidal Volume - volume of a normal inspiration or expiration during relaxed breathing
FRC - Functional Residual Capacity - volume of air remaining in the lung after a normal
expiration
VC - Vital Capacity - the total lung capacity minus the residual volume
FEF - Forced Expiratory Flow
FVC - Forced Vital Capacity - maximum volume of gas an individual can exhale
with force after a maximum inspiratory effort
FEV1- Forced Expiratory Volume in the first second after a maximal inspiratory
effort
DLCO- Diffusing capacity of carbon monoxide
Pulmonary Hypertension (PH) - occurs when blood pressure in the pulmonary artery is too high. Increased pressure within the lung causes the right ventricle of the heart to become enlarged and may result in shortness of breath, syncope (fainting), dizzy spells and heart failure. [PH Assn] [PH Central] [PPH Cure Foundation]
PPH, or primary pulmonary hypertension, exists when its cause is unknown. This condition is extremely rare.
PH, pulmonary hypertension, occurs as a result of other medical conditions, including COPD. PH is sometimes referred to as SPH (secondary PH)
Pulmonary Insufficiency (PI) - Chronic impairment of gas exchange due to clinically documented pulmonary disease .
Pulmonary Rehabilitation (PR) - a personalized program which incorporates therapy, support and education in attempting to assist the patient achieve the maximum obtainable functional capacity allowed by his handicap.
Pursed Lip Breathing (PLB) - technique used to slow breathing to maintain even lung pressure and control shortness of breath

Q
Quality of Life (QOL) - is defined as the 'physical, social and emotional aspects of a patient's well-being that are relevant and important to the individual'.

R
Rating of Perceived Exertion (RPE) - a self-assessment scale to rate breathlessness and fatigue during exercise.
Reactive Airway Disease (RAD) - condition caused by reaction to a trigger (i.e. allergen, odor or hypersensitivity). Asthma and Hypersensitivity Pneumonitis are examples of RAD.
Rescue Medication - short-acting medication designed to relieve symptoms quickly
Residual Volume (RV) - amount of air left behind after a maximum expiratory effort; lowest voluntary volume obtainable
Respiration - Respiration has two meanings in physiology. Along with breathing, respiration includes all chemical processes that occur in the body converting oxygen and food to water, energy and carbon dioxide.
Respiratory Distress Syndrome (RDS) - breathing complications experienced by newborns when immature lungs lack enough surfactant to keep air spaces open. Also called hyaline membrane disease.
Respiratory System - entire system of organs and tissues involved in breathing; these include the nose, throat, larynx, trachea, bronchi and lungs

S
SaO2 - percent saturation of hemoglobin with oxygen in the arterial blood; in the venous blood - SvO2
Shock Lung - clinical terminology for Adult Respiratory Distress Syndrome (ARDS)
Signs - objective findings discovered by a physician, i.e. heart murmur. See symptoms
Spacer - device designed to hold an aerosol metered-dose inhaler (MDI) for optimum delivery of the drug into the lungs; i.e. Aerochamber®
Spirometer - an instrument for measuring volume of air entering and leaving the lungs
Spirometry - best test available in primary care for early detection of many lung disorders, this procedure provides following key parameters
Forced Vital Capacity (FVC)
Forced Expiratory Volume in 1st second following maximal inspiration (FEV1)
Forced Expiratory Ratio in 1st second (FEV1/FVC%)
Spontaneous Pneumothorax (SP) - an inherited condition characterized by weak areas in the pleural lining of the lung. Small air-filled blisters, called blebs, may form which occasionally rupture causing air to leak from the lung into the chest cavity. Also called Blebs Disease.
Sputum - mucus, phlegm or other substances coughed up from the respiratory tract
Symptoms (SX) - subjective indications experienced by the patient, i.e. chest pain (see signs)

T
Tachycardia - relatively rapid heart rate
Tachypnea - increased rate of respiration
Thoracoscope - instrument used to directly visualize the pleura and lung surfaces; introduced into the thorax under general anesthesia, it facilitates the collection of tissue samples (see Open Lung Biopsy)
Thorascopy (VATS) - a minimally invasive "keyhole" surgical procedure which allows the surgeon to directly examine the chest cavity without a big incision. Often referred to as VATS (Video Assisted Thoracic Surgery)
Thoracotomy - surgical incision of the chest wall
Tidal Volume (TV or VT) - volume of a normal inspiration or expiration during relaxed (normal) breathing
Total Lung Capacity (TLC) - volume of the lungs after a maximum voluntary inspiration
Transplant (TX or XP) - surgery to replace a diseased organ or organs with healthy ones from a human donor.
Transtracheal oxygen (TTO2) - delivery of oxygen by insertion of a thin catheter directly into the trachea.

U
Upper Respiratory Infection (URI) - affecting any, or a combination, of the five parts comprising the upper respiratory tract: nose, sinuses, pharynx, larynx, trachea
Usual Interstitial Pneumonia (UIP) - a later stage of idiopathic pulmonary fibrosis (IPF), it is more patchy in appearance than DIP with marked interstitial infiltrate and thickening of alveolar walls

V
Vanishing Lung Syndrome - a progressive disorder characterized by presence of large upper lobe bullae occupying at least one-third of the hemithorax, and compressing surrounding normal lung. Also called "type 1 bullous disease" and "primary bullous disease of the lung.
Ventilation - the movement of gas in and out of the lungs to facilitate blood oxygenation and carbon dioxide removal
Ventilation Perfusion (VQ) Scan - a test that compares right and left lung function (blood flow and gas exchange) through the use of a small amount of radioactive material.
Ventilators - machines used in operating rooms (OR) and intensive care units (ICU) for respiratory support of patients who cannot breathe on their own. There are five main parameters:
1. Tidal Volume (egg. 700 ml) [Volume of gas injected into trachea with each breath]
2. Respiratory Rate (egg. 12 breaths/minute)
3. FIO2 (Fraction of Inspired Oxygen) (egg. 0.6 or 60% oxygen)
4. PEEP (Positive End Expiratory Pressure) (egg. 5 cm H2O)
5. I:E ratio (egg. 1:3) Time for inspiration in relation to time for expiration
Ventricle - one of the two pumping chambers of the heart; the right ventricle receives oxygen-poor blood from the right atrium and pumps it to the lungs through the aorta
Video Assisted Thoracic Surgery (VATS) - Thorascoscopy is a minimally invasive 'keyhole' surgical procedure which allows the surgeon to directly examine the chest cavity without a big incision.]
Virus - organism that causes a wide variety of infections, including colds and influenza. What the Heck is a Virus explains these unique entities.
Vital Capacity (VC) - the maximum volume of air that can be exhaled following a complete lung inflation. The difference between Total Lung Capacity (TLC) and Residual Volume (RV).

W
Wheezing - the sound made by air moving through partially obstructed airways

X
X-Ray - a form of electromagnetic radiation which can penetrate a body to produce in image on film.

• Bowers AC, Thompson, JM: Clinical Manual of Health Assessment, ed. 4, St Louis, 1992, Mosby.
• A Guide to Physical Examination and History Taking, Ninth Edition by Barbara Bates, published by Lippincott in 2005
• Malasanos L et al: Health Assessment, ed. 4, 1990, St Louis, Mosby.
• Wilkins RL, Sheldon RL, Krider SJ, editors: Clinical Assessment in Respiratory Care, ed. 5, St Louis, 2005, Mosby.
• JCAHO: Guide to Priority Focus Areas-Patient Assessment, JCAHO, 2004