Patient Assessment Part 3: Palpation, Percussion, Auscultation, Vital Signs, Lab Results

Palpation

• Assess chest wall by touch to confirm/rule-out suspected problems.
• Tracheal deviation
  • Finger at sternal notch; trachea should be midline.
  • Shifts toward unaffected side: pneumothorax, pleural effusion.
  • Shifts toward affected side: fibrosis, atelectasis.
• Chest excursion: thumbs should move equally $3\text{–}5\,\text{cm}$.
• Tactile fremitus (vibrations)
  • ↑ with consolidation, atelectasis, pulmonary edema.
  • ↓/absent with large pleural effusion, pneumothorax, hyperinflation.
• Crepitus (subcutaneous emphysema): crackling "rice-krispies" from air in tissue.

Percussion

• Tap middle finger systematically, compare sides.
• Notes
  • Resonance = normal.
  • Dullness (↑ density): atelectasis, consolidation, pleural effusion, fibrosis.
  • Hyperresonance (air trapping): COPD, asthma, pneumothorax.
• Diaphragmatic excursion in adults: $4\text{–}8\,\text{cm}$; ↓ with hyperinflation.

Auscultation

• Patient upright, breathe through mouth; follow zig-zag pattern anterior/posterior.
• Normal breath sounds
  • Bronchial: harsh over trachea only.
  • Vesicular: soft over most lung fields.
  • Bronchovesicular: 1st/2nd ICS & between scapulae.

Adventitious Breath Sounds

• Bronchial in periphery → consolidation/atelectasis.
• Diminished: low-intensity, poor air movement/obesity.
• Crackles
  • Fine (late insp.): collapsed small airways—atelectasis, fibrosis, early CHF, pneumonia.
  • Coarse: secretions in large airways—severe pneumonia, COPD, CF; may clear with cough.
• Wheeze: high-pitched musical; bronchospasm (asthma).
• Pleural friction rub: creaking, localized; pleurisy, pneumonia.
• Stridor: loud inspiratory crow; upper-airway obstruction (croup, epiglottitis, foreign body, post-extubation edema).

Vocal Fremitus Tests

• Bronchophony: "99" loud/clear → consolidation.
• Whispered pectoriloquy: whispered $1\text{–}2\text{–}3$ loud/clear → consolidation.
• Egophony: "ee" heard as "ay" → consolidation.

Heart Sounds

• $S_1$: mitral/tricuspid close (start systole).
• $S_2$: aortic/pulmonic close (end systole).

Vital Signs

• Pulse
  • Normal adult rate $60\text{–}100\,\text{bpm}$; tachy >$100$; brady <$60$.
  • Assess rate, rhythm, strength (strong, thready, bounding). Pulsus paradoxus ↓ pulse during inspiration (severe asthma).
• Blood Pressure
  • Normal ≈ $120/80\,\text{mmHg}$.
  • Hypertension >$140/90$ (cardiac stress, hypoxemia).
  • Hypotension <$90/60$ (poor perfusion). Orthostatic drop on standing.
• Respiratory rate: normal $12\text{–}20\,\text{bpm}$; count unobtrusively.
• Temperature: normal $37^\circ\text{C}$ ($98.6^\circ\text{F}$); hypo-/hyperthermia abnormal.
• SpO$<em>2$ normal $93\text{–}97\%$; $90\%\approx60\,\text{mmHg}$ PaO$</em>2$ (5–6–7–8–9 rule).

Complete Blood Count (CBC)

• RBC: $4\text{–}6\times10^6/\text{mm}^3$; ↑ polycythemia (chronic hypoxemia), ↓ anemia.
• Hemoglobin: $12\text{–}16\,\text{g/dL}$; mirrors RBC changes.
• Hematocrit: $40\text{–}50\%$.
• WBC: $5\text{–}10\times10^3/\text{mm}^3$; ↑ (leukocytosis) bacterial, ↓ (leukopenia) viral/sepsis.
• Platelets: $150\text{–}400\times10^3/\text{mm}^3$; essential for clotting.

Renal Function

• Creatinine: $0.7\text{–}1.3\,\text{mg/dL}$ (↑ kidney failure).
• BUN: $8\text{–}25\,\text{mg/dL}$ (↑ kidney failure).

Electrolytes

• Sodium $Na^+$: $135\text{–}145\,\text{mEq/L}$; hypo- (diuretics/vomiting), hyper- (renal failure). T-wave changes.
• Potassium $K^+$: $3.5\text{–}5.0\,\text{mEq/L}$; hypo- (diuretics/diarrhea), hyper- (renal failure). Flattened vs spiked T-waves.
• Chloride $Cl^-$: $96\text{–}106\,\text{mEq/L}$; mirrors $Na^+$ (metabolic alkalosis/ acidosis).
• Bicarbonate $HCO_3^-$: $22\text{–}26\,\text{mEq/L}$; base component of acid-base balance.

Additional Laboratory Tests

• Culture & sensitivity sputum: dx infection; results $48\text{–}72\,\text{h}$.
• D-dimer: normal <$0.5\,\text{mg/L}$; ↑ indicates thrombus/embolus.
• BNP: <$100\,\text{pg/mL}$ rules out heart failure.
• Troponin (high-sensitivity): normal <$14\,\text{ng/L}$; ↑ within $3\text{–}4\,\text{h}$ after myocardial injury.
• Prothrombin time / INR: normal INR ≤$1.1$; therapeutic $2.0\text{–}3.0$ on warfarin; ↑ = slow clotting, ↓ = fast clotting.