Pulm, Abd & Cards PE

Abnormalities of respiratory pattern can indicate pulmonary, metabolic, or neurologic abnormalities

Calculates rate of breathing

Observes rhythm and depth of breathing

Observes effort of breathing

Respiratory distress occurs when breathing does not meet metabolic demand for oxygen

Observes for signs of respiratory distress (tachypnea, cyanosis, pallor, audible sounds of breathing, accessory muscle use, flaring of nares, pursed-lip breathing)

_______ can occur in tension pneumothorax, large pleural effusion, or severe atelectasis

Inspects trachea for lateral displacement

______ can be seen in advanced emphysema

Observes ratio of AP diameter to lateral diameter of chest

Detects structural abnormalities of chest or lung pathology that impairs movement (e.g., tagging from pleural disease)

Inspects posterior thorax for chest wall deformities or asymmetry of chest expansion or respiratory movement.

Identifies areas of pain, inflammation, or subcutaneous emphysema

Palpates posterior thorax for tenderness or crepitus

Evaluates symmetry and extent of lung inflation, which can be hindered by conditions like pneumonia, pleural effusion, or hemidiaphragm paralysis

Assesses chest expansion

Percusses intercostal spaces of posterior thorax for diaphragmatic excursion

In resource-poor environments or when there is high suspicion of focal pulmonary disease, increase number of auscultation sites

Auscultates 18 locations (9 on each side) over posterior and lateral thorax in a ladder pattern. Waits for full exhalation before moving to new position

These maneuvers detect changes in density of underlying tissue. See Bates for full discussion.

Assesses for symmetric tactile fremitus (See Figure 1)

Percusses intercostal spaces of posterior thorax in ladder pattern

Assesses for transmitted voice sounds with:

1. Egophony (positive = “ee” to “aa” changes)

2. Bronchophony (positive = increased intensity and clarity of vocalized “boy and toy” through stethoscope)

3. Whispered pectoriloquy (positive = clear perception of whispered “boy and toy” through stethoscope

A: Detects structural abnormalities of chest or lung pathology that impairs movement (e.g., tagging from pleural disease)

Inspects anterior thorax for chest wall deformities or asymmetry of chest expansion or respiratory movement

A: Identifies areas of pain, inflammation, or subcutaneous emphysema

Palpates anterior thorax for tenderness or crepitus

A: In resource-poor environments or when there is high suspicion of focal pulmonary disease, increase number of auscultation sites

Auscultates 10 locations (5 on each side) over anterior thorax in a ladder pattern. Waits for full exhalation before moving to new position

A: These maneuvers detect changes in density of underlying tissue. See Bates for full discussion

Assesses for symmetric tactile fremitus (See Figure 2)

Percusses intercostal spaces of anterior thorax in ladder pattern

Assesses for transmitted voice sounds with

1. Egophony (positive = “ee” to “aa” changes)

2. Bronchophony (positive = increased intensity and clarity of vocalized “boy and toy” through stethoscope)

3. Whispered pectoriloquy (positive = clear perception of whispered “boy and toy” through stethoscope

Can reveal obstetric or surgical history, liver dz, vascular dz, infections, or other pathology

Observes skin of abdomen for color changes, scars, striae, rashes, ecchymoses

Assess for body habitus, organomegaly, distension,

aneurysm, and others. Dilated veins (caput medusae) suggest portal hypertension.

Observes shape of abdomen from the side and from the front. Notes overall contour,

bulges, peristalsis, dilated veins, pulsations, or visible organs. Observes umbilicus for

bulges, bleeding, nodules, or discharge

Both ventral hernia and diastasis recti become more pronounced with crunch.

Has patient perform a “crunch” to accentuate abdominal wall defects.

Bruit in these areas, especially a continuous systolic/diastolic bruit, suggests vascular dz (e.g., renovascular HTN)

Auscultates with bell over aorta, renal arteries, iliac arteries, and femoral arteries

In the postoperative setting, a highly tympanic,

distended abdomen often indicates delayed return of bowel function

Percusses all 9 regions of the abdomen

CVA tenderness – especially in the absence of

paraspinal muscle tenderness – suggests renal inflammation

Assesses for CVA tenderness: places nondominant hand flat against the costovertebral angle. Makes a closed fist with the dominant hand, and strikes the nondominant hand softly at first, then with increasing force

These are signs of peritonitis suggesting surgical emergency

Palpates abdomen in all areas for guarding, rebound tenderness, and rigidity

These signs suggest appendicitis

Palpates for Rovsing’s sign

Assesses for the psoas sign

Assesses for the obturator sign

Performs heel tap

Positive fluid wave increases likelihood of ascites

Places one hand against the lateral wall of the abdomen and uses the other hand to

tap firmly on the opposite lateral wall. In the positive response, the tap generates a

wave that is transmitted through the abdomen and felt as a sudden shock by the other

hand

The liver is not normally palpable. Palpable liver

usually, but not always, indicates hepatomegaly.

Palpability of liver depends more on consistency than size.

Palpates liver edge

Right fingertips on patient’s right abdomen lateral to rectus at level of umbilicus

Left hand providing upward pressure beneath patient’s flank

Asks patient to take a deep breath and attempts to feel liver edge with right fingertips during inspiration. Notes size and consistency of liver, if palpable.

Positive Murphy’s sign suggests acute cholecystitis or other hepatobiliary dz

Assesses for Murphy’s sign if patient reports RUQ pain but does not have RUQ tenderness with regular palpation

Presses fingertips under the right costal margin, midclavicular line.

Asks the patient to take a deep breath (positive = sharp halting of inspiratory effort

due to pain)

Spleen is not normally palpable unless there is massive splenomegaly

Palpates spleen by curling fingers over the left costal margin in attempt to “hook” spleen edge.

Asks patient to take a deep breath and feels for spleen to “palpate” the fingertips

Widened or prominent pulsation suggests AAA, but absence of pulsation does not rule out AAA.

Palpates aorta in the epigastrium, slightly left of midline

Measures width of aorta by palpating with two hands on both sides of aorta.

Absence of palpable bladder decreases probability of bladder volume greater than 400mL

(i.e. urine retention)

Palpates suprapubic region for bladder

Jugular venous pressure closely parallels pressure in the right atrium, i.e., central venous pressure

Hepatojugular reflux – or sustained elevation in JVP on applying abdominal pressure – is a sign of right ventricular failure

• HoB at 30 degrees

• Uses tangential lighting to examine both sides of neck for JV pulsations.

• If necessary, adjusts HoB

• Patient’s head turned slightly away from examiner toward left

• Differentiates between internal and external jugular vein

• Identify the highest point of pulsation in the right internal jugular vein. Assess for

• Kussmaul’s sign (inappropriate persistence or increase in JVP with inspiration)

• Measures vertical distance in cm above the sternal angle and adds 5cm to calculate JVP

• Assesses for hepatojugular reflux: exposes RUQ, applies pressure to RUQ for 1min and monitors for persistent increase in JVP of more than 3cm

Carotid artery bruit or thrill can be an indication of carotid artery stenosis. Alternatively, the murmur of aortic valve stenosis can transmit to the carotid artery

• HoB at 30 degrees

• Instructs patient to breathe out and pause respirations.

• Auscultates both carotid arteries for bruit or radiation of murmur using bell. Positioned to the side of patient, not behind patient.

• Verbalizes auscultating aortic area if a systolic sound is noted.

• MUST auscultate prior to palpation to avoid dislodging atherosclerotic plaque

• Palpates carotid arteries separately (not simultaneously) for amplitude, contour, and

• presence of thrills. Does not place hand across patient’s throat to palpate L side

Chest wall tenderness can indicate MSK cause of chest pain

HoB at 30 degrees

Palpates chest wall for tenderness

Heaves are usually produced by enlarged right or left ventricle.

Thrills are signs of severe valvular disease.

Palpates chest wall for RV heave with palm of hand.

Palpates chest wall for thrills using fingertips

Various pathologies will displace or widen the point of maximal impulse

HoB at 30 degrees. (If unable to palpate PMI place patient in left lateral decubitus position with HoB at 0 degrees)

Palpates for PMI using one or two finger tips, starting at mid-clavicular line, 4th intercostal space

Assesses for S3, S4, and mitral murmurs

HoB at 0 degrees, patient in L lateral decubitus position, auscultating at apex with bell

Assesses for split of S2 sound

Patient sitting upright and breathing deeply, diaphragm at L sternal border at 2nd intercostal space

Assesses for aortic regurgitation

With patient leaning forward, asks patient to exhale completely and pause breathing.

Auscultates with diaphragm at L sternal border at 3rd intercostal space

Assesses for hypertrophic cardiomyopathy

With patient squatting, auscultates with diaphragm at L sternal border at 3rd intercostal space. Continues to auscultate as patient stands to detect increase in intensity of murmur.

If a murmur is detected, these maneuvers may augment the sound

If necessary, asks patient to augment murmur with respiration, Valsalva, isometric exercise, or leg elevation

• Assesses ulnar pulse

• Assesses brachial pulse

• Assesses popliteal pulse

• Assesses femoral pulse

• Assesses axillary nodes

• Assesses epitrochlear nodes

• Assesses inguinal and femoral nodes

• Palpates ulnar artery

• Palpates brachial artery

• Palpates popliteal artery

• Palpates femoral artery

• Palpates axillary lymph nodes

• Palpates epitrochlear lymph nodes

• Palpates inguinal and femoral lymph nodes

Warm temperature can indicate inflammation, while cool

temperature can indicate hypoperfusion or atherosclerosis

Use back of hand to palpate lower extremities for temperature

Capillary refill is a quick assessment of the state of perfusion at the fingertips, which can be reduced by shock or vascular disease

Check capillary refill: applies pressure to fingernail for about 5 seconds. Upon release of pressure, counts seconds until skin beneath fingernail recovers color. Normal is less than 3 seconds