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: