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