Patient Assessment – Inspection (RC121)

Physical Examination Sequence (IPPA)

• Inspection: primary & most informative step
• Followed by Palpation, Percussion, Auscultation

Dyspnea

• General breathing discomfort; worsened by anxiety
• Orthopnea: difficulty except upright (CHF)
• Platypnea: difficulty when upright (hepatopulmonary syndrome)
• Psychogenic dyspnea: panic-related; often with hyperventilation

Cough

• Protective, forceful expiratory maneuver
• Receptors in larynx, trachea, large bronchi; triggered by inflammation, mucus, foreign bodies, noxious gases
• Effectiveness depends on deep breath, elastic recoil, expiratory muscle strength, airway resistance
• Descriptors: strong/moderate/weak; dry vs. wet; productive vs. non-productive; acute vs. chronic; day vs. night

Sputum Evaluation

• Volume: scant → copious
• Odor: sweet vs. foul
• Color/consistency:
  • Clear = normal / mucoid (thick)
  • Purulent = pus
  • Mucopurulent = mucus + pus (yellow)
  • Brown/Dark = old blood
  • Bright red = hemoptysis
  • Pink, frothy = pulmonary edema
  • Yellow = WBC / bacterial
  • Green = stagnant / gram-negative; green + foul = Pseudomonas
  • Red, jelly-like = Klebsiella
  • Tenacious = sticky; Viscous = thick
• Massive hemoptysis: >300\,\text{mL} in 24\,\text{h} (emergency)
• Hematemesis = GI blood (vomit)

Chest Pain

• Pleuritic: sudden, sharp, worse on deep inspiration; causes—pleurisy, pneumonia, effusion, pneumothorax, infarction, CA, fungus, TB
• Non-pleuritic: constant, central; causes—myocardial ischemia, pericarditis, pulmonary HTN, esophagitis, chest wall trauma

Additional Symptoms & Signs

• Nose/throat: rhinorrhea, itching, dysphagia, hoarseness
• Fever: suggests infection; ↑T ⇒ ↑O2 demand ⇒ tachypnea
• Peripheral edema (arms/ankles): R-heart or renal failure; pedal, pitting, weeping varieties
• General malaise: nausea, weakness, HA; possible electrolyte loss
• Digital clubbing: painless enlargement of terminal phalanges; indicates chronic hypoxemia
• Skin color:
  • Cyanosis: \ge 5–6\,\text{g·dL}^{-1} desat Hgb; peripheral (digits, poor perfusion) vs. central (lips/tongue, urgent)
  • Pallor/Ashen: anemia, blood loss, vasoconstriction
  • Jaundice: hyperbilirubinemia/liver issues
  • Erythema: capillary congestion, inflammation, infection
• JVD: bulging external jugular; common in cor pulmonale (↑CVP)
• Capillary refill: normal \le2\,\text{s}; prolonged → low output/perfusion
• Diaphoresis: profuse sweating; seen in HF, fever, anxiety, TB (night sweats)

Thoracic Configuration

• Normal AP:Transverse ratio 1:2
• Barrel chest 1:1 (chronic air trapping—COPD, asthma, CF)
• Pediatric chest: normally 1:1 until \approx6 yrs

Chest Landmarks & Deformities

• Reference lines: mid-clavicular, mid-sternal, mid-spinal, mid-scapular, mid-axillary; suprasternal notch & Angle of Louis
• Pectus carinatum: sternum protrudes ("pigeon")
• Pectus excavatum: sternum depressed ("funnel")

Respiratory Distress Indicators

• Retractions: intercostal, substernal, supraclavicular, subcostal, tracheal tug
• Accessory muscle use
  • Inspiration: sternocleidomastoids, scalenes, traps, pectoralis major
  • Expiration: abdominal muscles, internal intercostals
• Chest excursion: symmetric vs. asymmetric (atelectasis, pneumothorax, flail chest, R-mainstem intubation)
• Flail chest: paradoxical segment movement

Breathing Patterns

• Eupnea: V_T\approx500\,\text{mL}\,(7–9\,\text{mL·kg}^{-1}), 12–20\,\text{bpm}, I:E 1:2
• Tachypnea >20 bpm; Bradypnea <12 bpm; Apnea = no breathing
• Apneustic: deep gasp + pause (brain injury)
• Hyperpnea (deep), Hypopnea (shallow)
• Hyperventilation: ↑rate/depth ⇒ ↓PaCO2; Hypoventilation ⇒ ↑PaCO2
• Biot’s: clusters of quick deep breaths + apnea (CNS damage)
• Cheyne–Stokes: crescendo-decrescendo + apnea (CNS, CHF)
• Kussmaul’s: deep/fast (DKA, metabolic acidosis)

Infant Distress

• Nasal flaring, grunting (creates PEEP), retractions
• Infants are preferential nose breathers

Breathing Technique

• Pursed-lip breathing: inhale 2 count nose → exhale \ge4 count lips; prolongs exhalation, reduces air trapping, calming

COPD Hallmark Findings

• Barrel chest, dyspnea, accessory muscle use, tripod positioning, digital clubbing, frequent infections, cor pulmonale, easily fatigued, orthopnea