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.
• SpO2 normal 93\text{–}97\%; 90\%\approx60\,\text{mmHg} PaO2 (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.