Chapter 2 – The Physical Examination

Vital Signs Overview

  • Four primary vital signs: Body Temperature (T), Pulse (P), Respiration (R), Blood Pressure (BP)
  • Pulse oximetry (SpO₂) = “fifth” vital sign

Body Temperature

  • Core set-point ≈ 37^{\circ}\text{C} ( 98.6^{\circ}\text{F} ); normal daily swing ±0.5^{\circ}\text{C}
  • ↑T → vasodilation | ↓T → vasoconstriction

Fever & Hypothermia

  • Fever patterns: intermittent, remittent, relapsing, constant
  • Hypothermia = core T below normal; major causes: excessive heat loss, poor heat production, hypothalamic failure
  • Key hypothermia signs: ↓P & ↓R, shivering, pale/blue cool skin, hypotension, oliguria, ataxia → coma
  • Immediate care: remove wet clothes, passive/active re-warming, warmed fluids

Factors & Measurement of Temperature

  • Influencers: age, environment, circadian cycle, exercise, stress, hormones
  • Common sites: oral, rectal, tympanic, axillary (others: esophageal, pulmonary artery)
  • Reliability = correct device + site + technique

Pulse

  • Generated each ventricular contraction
  • Adult ranges: bradycardia < 60\,\text{bpm} | tachycardia > 100\,\text{bpm}
  • Assess: rate, rhythm (regular/irregular), strength (strong, weak, thready, bounding)

Respiration Basics

  • Diaphragm = primary muscle; inspiration active, expiration passive
  • Normal adult rate 12!–!20\,\text{breaths·min}^{-1}

Common Breathing Patterns

  • Eupnea: normal ( 12!–!20 )
  • Bradypnea: <12
  • Tachypnea: >20
  • Apnea: absent breathing → arrest
  • Hypoventilation: ↓rate & depth → ↑PaCO₂
  • Hyperventilation: ↑rate & depth → ↓PaCO₂
  • Cheyne–Stokes: crescendo–decrescendo with apnea
  • Kussmaul: deep, rapid (metabolic acidosis)
  • Biot: clusters of rapid breaths with pauses

Blood Pressure Fundamentals

  • Arterial BP = force of blood on arterial walls
    • Systolic / Diastolic
    • BP = V \times R (flow × resistance)
  • Blood flow = cardiac output: CO = SV \times HR (≈ 5\,\text{L·min}^{-1})
  • Abnormalities:
    • Hypertension (primary/secondary) • Hypotension

Oxygen Saturation (SpO₂)

  • Normal 95!–!99\%
  • Mild 91!–!94\% | Moderate 86!–!90\% | Severe ≤85\%
  • Remember O₂-Hb dissociation: PaO₂ = 60\,\text{mmHg} \Rightarrow SpO₂ \approx 90\%

Signs of Inadequate Oxygenation

  • CNS: apprehension → confusion → coma
  • Respiratory: tachypnea → accessory use, retractions, word-by-word speech
  • Cardiovascular: tachycardia/HTN → arrhythmias → hypotension, cyanosis, cool clammy skin
  • Other: diaphoresis, ↓urine output, fatigue

Chest & Lung Examination Sequence

  1. Inspection
  2. Palpation
  3. Percussion
  4. Auscultation

Palpation Highlights

  • Evaluate chest expansion symmetry (thumbs at T8!–!T10)
  • Check tracheal position, tenderness, masses, temperature
  • Fremitus:
    • Tactile: vibration from air through secretions
    • Vocal: vibration during phonation

Percussion Essentials

  • Determines underlying air/liquid/solid, size & borders
  • Dull note: pleural effusion, consolidation, atelectasis
  • Hyperresonant: COPD, pneumothorax, asthma
  • Limited diaphragmatic excursion: hyperinflation, lobar collapse, neuromuscular disease

Auscultation & Breath Sounds

  • Normal: bronchial, bronchovesicular, vesicular
  • Abnormal (record pitch, loudness, phase, quantity, location):
    • Fine/medium/coarse crackles • Wheezes • Stridor • Pleural friction rub • Diminished • Bronchial in wrong area • Whispering pectoriloquy
  • Avoid obsolete terms: rales, rhonchi, etc.