Chapter 6 PHYSIOTHERAPY ASSESSMENT

Problem Oriented Medical Records (POMR)

  • Widely used method for recording patient assessment, management, and progress.

  • Divided into five sections:

    • Data base

    • Problem list

    • Initial plan and goals

    • Progress notes

    • Discharge summary

Database

  • Personal details, medical history, relevant social history, investigation results, and physiotherapist's assessment are recorded.

Problem List

  • Concise list of patient's problems compiled after assessment.

  • Problems not always in order of priority.

  • Includes problems both related and unrelated to physiotherapy.

  • Resolution of problems and appearance of new ones are noted.

Initial Plan and Goals

  • Treatment plan formulated to address physiotherapy-related problems, considering other patient problems.

  • Long- and short-term goals are formulated.

    • Long-term goals: what the patient and physiotherapist want to achieve, related to the problems.

    • Short-term goals: stages to achieve long-term goals.

Progress Notes

  • Document patient's progress, highlighting changes.

  • Written in SOAP format (subjective, objective, analysis, plan) for each problem.

  • Provide an up-to-date summary of patient's progress.

Discharge Summary

  • Written when patient is discharged or transferred.

  • Includes:

    • Presenting problems

    • Treatment given

    • Outcomes of treatment

    • Home program or follow-up instructions

Subjective Assessment

General Assessment

  • Information from medical notes or questioning the patient.

  • Format may vary but contains same information.

  • Includes patient's personal details:

    • Name

    • Date of birth (Age)

    • Gender

    • Occupation

    • Address

    • Hospital number

    • Referring doctor

    • Diagnosis and reason for referral

    • Marital status

    • Religion, etc.

Chief Complaint

  • More Priority (Due to this patient visit to hospital)

  • Must be written in Patient own words don’t use medical terms

  • Subjective assessment based on interview with the patient.

  • Start with open-ended questions:

    • What is the main problem?

    • What troubles you most?

  • Allows patient to discuss most important problems.

  • Previously unmentioned problems may surface.

  • Questioning becomes more focused on important features needing clarification as the interview progresses.

Symptoms of Respiratory Disease

  • Five main symptoms:

    • Breathlessness (dyspnoea)

    • Cough

    • Sputum and haemoptysis

    • Wheeze

    • Chest pain

  • Enquiries should be made concerning:

    • A symptom is a phenomenon that is experienced by the individual affected by the disease, while a sign is a phenomenon that can be detected by someone other than the individual affected by the disease

    • Duration: time since first recognition and duration of present symptoms.

    • Severity: in absolute terms and relative to the recent and distant past.

    • Pattern: seasonal or daily variations.

    • Associated factors: precipitants, relieving factors, and associated symptoms.

Breathlessness (Dyspnoea)

  • Subjective awareness of increased work of breathing.

  • Predominant symptom of cardiac and respiratory disease.

  • Specific names for patterns of breathlessness:

    • Orthopnoea: breathlessness when lying flat.

    • Paroxysmal nocturnal dyspnoea (PND): breathlessness that wakes the patient at night.

  • Severity assessed through The New York Heart Association classification of breathlessness:

    • Class I: No symptoms with ordinary activity; breathlessness only with severe exertion (e.g., running up hills).

    • Class II: Symptoms with ordinary activity (e.g., walking up stairs, making beds).

    • Class III: Symptoms with mild exertion (e.g., bathing, showering, dressing).

    • Class IV: Symptoms at rest.

  • Description of onset:

    • Date

    • Time

    • Type: sudden/gradual

  • Setting

    • Cause

    • Circumstances

    • Activities surrounding onset

  • Severity(NYHACB)

    • How bad it is

    • How it affects activities of daily living

  • Frequency

    • How often

  • Duration

    • How long

    • Constant/intermittent

  • Course

    • Better/worse/same

  • Associated symptoms

    • Sweating

    • Cough

    • Chest discomfort

  • Aggravating factors

    • Position/weather/temperature/anxiety/exercise

  • Reliving factors

    • Position/hot/cold/rest

  • During the status of episode

    • Can you continue to do what you were doing

    • Do you have to sit down or lie down

    • Can you continue to speak

  • Do the attack cause your lips or nail bed to turn blue

  • Modified Borg scale:

Activities Disturbed by Breathlessness

  • Climbing stairs

  • Walking

  • Bathing

  • Toileting

  • Dressing

  • Combing

  • Shopping

  • Grooming

  • Speaking

  • Any other activities

Cough

  • Protective reflex to rid airways of secretions or foreign bodies.

  • Stimulation of receptors in pharynx, larynx, trachea, or bronchi may induce cough.

  • Difficult symptom to clarify as most people cough normally every day, yet a repetitive persistent cough is both troublesome and distressing.

  • Important features:

    • Its effectiveness

    • Whether it is productive or dry

  • Postoperatively, the strength and effectiveness of cough is important for the physiotherapist to assess.

Cough Description

  • Onset

    • Date

    • Time

    • Type – Sudden or Gradual

  • Duration

    • How long it last?

    • Constant or intermittent?

  • Description of cough

    • Effective-strong enough to clear the airway

    • Inadequate –audible but too weak to mobilize secretions

    • Productive (mucous or other material is expelled by the cough)

    • Dry -moisture or secretions are not produced

  • Quality

    • Characteristics

    • Barking/brassy(harsh & dry)/hoarse/with stridor/wheezy/hacking

  • Quantity- How many?

  • Severity

    • How bad it is?

    • How it affects activity of daily living?

  • Productive/non productive

  • Setting

    • Cause

    • Circumstances

    • Activity surrounding onset

  • Frequency

    • How often?

    • Particular day/ particular week/particular season

  • Associated symptoms

    • Chest pain/wheezing/fever/runny nose/hoarseness/night sweat/weight loss/head ache/dizziness/ loss of consciousness

  • Aggravating factors

    • Position/weather/temperature/anxiety/exercise/ smoking/eating/drinking/ particular location

  • Relieving factors

    • Position/hot/cold/rest/medications

  • Clinical presentation of cough

    • Acute

    • Sudden

    • Paroxysmal

Sputum and Haemoptysis

  • Normal adult produces approximately 100 ml of tracheobronchial secretions daily, cleared subconsciously.

  • Sputum is excess tracheobronchial secretions cleared by coughing or huffing.

  • May contain mucus, cellular debris, microorganisms, blood, and foreign particles.

Sputum Analysis

  • Description

    • Mucoid (clear or white)/ mucopurulent/purulent (contains pus cells) / blood tinged

      • GRADES

        • M1 mucoid with no suspicion of pus

        • M2 predominantly mucoid, suspicion of pus

        • P1 1/3 purulent, 2 /3 mucoid

        • P2 2/3 purulent 1/3 mucoid

        • P3 > 2 / 3 purulent

  • Color

    • Clear/colorless like egg white/black/brownish/frothy white/pink/sand

    • Greenish/red jelly/rusty

  • Consistency

    • Thin/thick/viscous/tenacious/frothy

  • Quantity

    • Scanty/ _teaspoon/cup/copious __ pint or more

  • Time of the day

    • Morning/evening

  • Odor

  • Presence of blood

  • Other distinguishable material

Sputum Causes

  • Saliva: Clear watery fluid

  • Mucoid: Opalescent or white; Chronic bronchitis without infection, asthma

  • Mucopurulent: Slightly discoloured, but not frank pus; Bronchiectasis, cystic fibrosis, pneumonia

  • Purulent: Thick, viscous: Yellow Dark green/brown Rusty Red currant jelly; Haemophilus Pseudomonas Pneurnococcus. mycoplasma Klebsiella

  • Frothy: Pink or white; Pulmonary oedema

  • Haemoptysis: Ranging from Wood specks to frank blood, old blood (dark brown); Infection (tuberculosis, bronchiectasis), infarction, carcinoma, vasculitis, trauma, also coagulation disorders, cardiac disease

  • Black: Black specks in mucoid secretions; Smoke inhalation (fires, tobacco, heroin), coal dust

Wheeze

  • Whistling or musical sound produced by turbulent airflow through narrowed airways.

  • Generally noted by patients when audible at the mouth.

Chest Pain

  • In respiratory patients usually originates from musculoskeletal, pleural or tracheal inflammation, as the lung parenchyma and small airways contain no pain fibres.

  • Pleuritic chest pain is caused by inflammation of the parietal pleura, and is usually described as a severe, sharp, stabbing pain which is worse on inspiration. It is not reproduced by palpation.

  • Tracheitis generally causes a constant burning pain in the centre of the chest aggravated by breathing.

  • Musculoskeletal (chest wall) pain may originate from the muscles, bones, joints or nerves of thoracic cage. It is usually well localized and exacerbated by chest and/or arm movement. Palpation will usually reproduce the pain.

  • Angina pectoris is a major symptom of cardiac disease. Myocardial ischaemia characteristically causes a dull central retrosternal gripping or band-like sensation which may radiate to either arm, neck or jaw.

  • Pericarditis may cause pain similar to angina or pleurisy.

Chest Pain Origin and Description

  • Origin

    • location

  • Onset

    • Date

    • Time

    • Type Sudden/gradual

  • Pattern

    • Frequency

    • Recurrence

    • Duration

    • Constant or intermittent

    • Course

  • Provoked symptoms(aggravating factors)

    • Breathing

    • Positions

    • Movement with arms

    • Rest/exercise

    • Sleeping/stress/after eating

    • Stress/anxiety

  • Quality

    • Dull/ aching/pin prickling/throbbing/knife like/sharp/constricting/sticking/burning/shooting/tearing

  • Radiating

  • Referred

  • Relieving factors

    • Rest

    • Positions

    • Analgesics

    • Antacids

    • Hot

    • Cold

  • Severity

    • How it affects ADL

    • VAS scale

  • Associated symptoms

    • Coughing/breathlessness/palpitations/ hemoptysis/vomiting/ leg pain/weakness/muscle fatigue

  • Time frame

    • Acute/chronic

  • Past treatment

    • Past history of pain

    • How it subsided/rest/medicines

    • Past history of heart attack/recent infection /history of pulmonary disease/accidents

  • Family history of heart disease

  • What do you think is wrong

    • Is this different from previous episodes

Other Symptoms

  • Fever (pyrexia) is one of the common features of infection, but low-grade fevers can also occur with malignancy and connective tissue disorders. Equally, infection may occur without fever, especially in immunosuppressed (e.g.chemotherapy) patients or those on corticosteroids. High fevers occurring at night, with associated sweating (night sweats), may be the first indicator of pulmonary tuberculosis.

  • Headache is an uncommon feature of respiratory disease. Morning headaches in patients with severe respiratory failure may signify nocturnalcarbon dioxide retention. Early morning arterial blood gases or nocturnal transcutaneous carbon dioxide monitoring are required for confirmation.

  • Peripheral oedema in the respiratory patient suggests right heart failure which may be due to cor pulmonale (right ventricular failure secondary to hypoxic pulmonary vasoconstriction). Peripheral oedema may also occur in patients taking high-dose corticosteroids, as a result of salt and water retention.

Functional Ability

  • Assess patient as a whole, enquiring about daily activities.

  • If employed, what does his job actually entail?

  • Home situation should also be documented, in particular the number of stairs to the front door and within the house.

  • With whom does the patient live?

  • What roles does the patient perform in the home (shopping, housework, cooking)?

  • Finally, questions concerning activities and recreation often reveal areas where significant improvements in quality of life can be made.

Associated Symptoms

  • Hemoptysis

  • Hoarseness

  • Voice changes

  • Dizziness/fainty syncope

  • Head ache

  • Altered sensorium

  • Ankle swelling

  • Cyanosis

Constitutional Symptoms

  • Fever

  • Excessive sweating/Night sweating

  • Loss of appetite

  • Nausea

  • Vomiting

  • Weight loss

  • Fatigue

  • Weakness/Malaise

  • Exercise intolerance

  • Altered sleep pattern

History

  • Summarizes history from medical notes and assessment.

  • Divided into several sections:

    • Present/current history

    • Past history

    • Medical and surgical histories

    • Drugs/medicine history

    • Family history

    • Social history

History of Presenting Condition (HPC)

  • Summarizes patient's current problems, including relevant information from medical notes.

  • General

    • The following characteristics of each symptom should be elicited and explored:

      • Onset – sudden or gradual

      • Location - radiation

      • Duration – frequency, chronology

      • Characteristics – quality, severity

      • Aggravating and precipitating factors

      • Relieving factors

      • Current situation (improving or deteriorating)

      • Effects on Activities of Daily Living (ADL)

      • Previous diagnosis of similar episodes

      • Previous treatments and efficacy

Previous Medical History (PMH)

  • Summarizes entire list of medical and surgical problems that the patient has had in the past.

  • It may be written in disease-specific groupings or as a chronological account.

    • Surgeries & hospitilisation

    • Injuries & accidents

    • Immunization

    • Allergies

    • Medications

Drug History (OH)

  • List of patient's current medications (including dosage) taken from the medication charts. Drug allergies should also be noted.

Family History (FH)

  • Includes a list of any major diseases suffered by members of the immediate family.

Family History (Specific to Cardio-respiratory Systems)

  • Others at home with similar symptoms

  • Allergies,

  • Asthma, lung cancer, TB, cystic fibrosis, bronchitis

  • Diabetes mellitus

  • Heart disease: hypertension, ischemic coronary artery disease, MI (especially in family members < 50 years of age), sudden death from cardiac disease, dyslipidemia, hypertrophic cardiomyopathy

Social History (SH)

  • Provides a picture of the patient's social situation.

  • Important to specifically question the patient about the level of support available at home (Economic History), and to gain an idea of the patient's expected contribution to household duties.

  • The layout of the patient's home should also be ascertained with particular emphasis on stairs (Environmental History).

  • Occupation and hobbies, both past and present, give further information about the patient's lifestyle.

  • Finally, history of smoking and alcohol use should be noted.

Personal History

History of smoking

  • Yes/no

  • Types of tobacco

  • How old when the patient begin smoking

  • How many years the patient smoked

  • How many cigarettes smoked each day

  • Any variation in smoking habits

  • Any attempt to stop smoking

  • Date when the patient last smoked

  • Pack year:

History of alcohol intake

  • yes/no

  • How old when the patient started alcohol

  • How many years the patient consumed

  • How many pegs each day

  • Any variation in alcoholic habits

  • Any attempt to quit alcohol

  • Date when the patient last taken

Personal and Social History (Specific to Cardio-respiratory Systems)

  • Exposure to second hand smoke, wood smoke, pets, mould

  • Crowded living conditions

  • Poor personal or environmental cleanliness

  • High stress levels (personal or occupational)

  • Institutional living

  • Occupational or environmental exposure to respiratory irritants (mining, forest fire fighting)

  • Substance use (e.g., alcohol, caffeine, street drugs, including injection and inhaled drugs / solvents)

  • Human immunodeficiency virus (HIV) risks

  • Obesity

  • Immigration or travel abroad

Objective Assessment

Vital Signs

  • Temperature

  • Pulse/Heart rate

  • Respiratory rate

  • Blood pressure (BP)

  • The patient's chart should then be examined for recordings of temperature, pulse, blood pressure and respiratory rate.

  • These measurements are usually performed by the nursing staff immediately on admission of the patient and regularly thereafter.

Temperature

  • Body temperature is maintained within the range 36.5−37.5°C36.5-37.5°C. It is lowest in the early morning and highest in the afternoon.

  • Body temperature can be measured in a number of ways.

  • Oral temperatures are the most convenient method in adults but should not be performed for at least 15 minutes after smoking or consuming hot or cold food or drink.

  • Axillary and rectal temperature may also be measured.

  • Normal temperature: 36.6−37.236.6-37.2 degree Celsius, 98−9998-99 degree Fahrenheit

  • Febrile: > 37.2 degree Celsius, >99 degree Fahrenheit

  • Hyperpyrexia: > 41.6 degree Celsius, >107 degree Fahrenheit

  • Subnormal: < 36.6 degree Celsius, < 98 degree Fahrenheit

  • Hypothermia: < 35 degree Celsius, <95 degree Fahrenheit

  • Fever (pyrexia) is the elevation of the body temperature above 37.5°C37.5°C, and is associated with an increased metabolic rate. For every 0.6°C0.6°C (1°F1°F) rise in body temperature, there is an approximately 10%10\% increase in oxygen consumption and carbon dioxide production. This places extra demand on the cardiorespiratory system which causes a compensatory increase in heart rate and respiratory rate.

Heart Rate

  • Heart rate is most accurately measured by auscultation at the cardiac apex.

  • The normal adult heart rate is 60-100 beats per minute.

  • The pulse rate is measured by palpating a peripheral artery (radial, femoral or carotid). In most situations, the heart rate and pulse rate are identical;

  • A difference between the two is called the 'pulse deficit'. This indicates that some heart beats have not caused sufficient blood flow to reach the periphery and is commonly found in atrial fibrillation and some other arrhythmias.

Rate, Rhythm, Volume, Force, Tension

  • Rate: Normal pulse rates at rest, in beats per minute (BPM)

  • Rhythm: A normal pulse is regular in rhythm and force.

  • Volume: The degree of expansion displayed by artery during diastolic and systolic state is called volume(pulse pressure= Sys-Dis). It is also known as amplitude, expansion or size of pulse.

  • Force: Also known as compressibility of pulse. It is a rough measure of systolic blood pressure.

  • Tension: It corresponds to diastolic blood pressure.

  • Condition of arterial wall- A normal artery is not palpable after flattening by digital pressure (role the artery)

  • Equality- Comparing pulses and different places gives valuable clinical information.

  • Apex beat-pulse corelation- 'pulse deficit

  • Tachycardia is defined as a heart rate greater than 100 beats/min at rest. It is found with anxiety, exercise, fever, anaemia and hypoxia. It is also common in patients with cardiac disorders. Medications such as bronchodilators and some cardiac drugs may also increase heart rate.

  • Bradycardia is defined as a heart rate less than 60 beats/min. It may be a normal finding in athletes and may also be caused by some cardiac drugs (especially beta-blockers).

Common Palpable Sites

  • Carotid artery: It can be felt between the anterior border of the sternocleidomastoid muscle, above the hyoid bone and lateral to the thyroid cartilage

  • Brachial pulse: located on the inside of the upper arm near the elbow, frequently used in place of carotid pulse in infants

  • Radial pulse: located on the lateral of the wrist (radial artery).

  • Femoral pulse: located in the inner thigh, at the mid-inguinal point, halfway between the pubic symphysis and anterior superior iliac spine

  • Dorsalis pedis pulse: located on top of the foot, immediately lateral to the extensor of hallucis longus

  • Tibialis posterior pulse: located on the medial side of the ankle, 2 cm inferior and 2 cm posterior to the medial malleolus

  • Popliteal pulse: Above the knee in the popliteal fossa, found by holding the bent knee. The patient bends the knee at approximately 124° , and the physician holds it in both hands to find the popliteal artery in the pit behind the knee

Blood Pressure (BP)

  • With every contraction of the heart (systole) the arterial pressure increases, with the peak called the 'systolic' pressure.

  • During the relaxation phase of the heart (diastole), the arterial pressure drops, with the minimum called the 'diastolic' pressure.

  • Blood pressure is usually measured non-invasively by placing a sphygmomanometer cuff around the upper arm, and listening over the brachial artery with a stethoscope.

  • Cuff inflation to above systolic pressure collapses the artery, blocking flow.

  • With release of the air, the cuff pressure gradually falls to a point just below systolic.

  • At this point, the peak pressure within the artery is greater than the pressure outside the artery, so flow recommences.

  • This turbulent flow is audible through the stethoscope.

  • As the cuff is further deflated the noise continues When the cuff pressure drops to just below diastolic, the pressure within the artery is greater than that of the cuff throughout the cardiac cycle, so turbulence abates and the noise ceases.

  • Blood pressure is recorded as systolic/ diastolic pressure.

  • Normal adult blood pressure is between 95/60 and 140/90 mmHg

  • Hypertension is defined as a blood pressure of greater than 145/95 mmHg, usually due to changes in vascular tone and / or aortic valve disease.

  • Hypotension is defined as a blood pressure of less than 90/60 mmHg. It is often a normal finding during sleep. Daytime hypotension may be due to heart failure, blood loss or decreased vascular tone.

  • Postural hypotension is a drop in blood pressure of more than 5 mmHg between lying and sitting or standing, and may be due to decreased circulating blood volume, or loss of vascular tone.

  • Pulsus paradoxus- drop in blood pressure that occurs with inspiration. blood pressure drops by more man 10 mmHg is seen in situations where the intrathoracic pressure swings are greater, as occurs in severe airway obstruction.

Respiratory Rate

  • Respiratory rate should be measured with the patient seated comfortably.

  • The normal adult respiratory rate approximately 12-18 breaths/min.

  • Tachypnoea is defined as a respiratory rate greater than 20 breaths /min, and can be seen in any form of lung disease. It may also occur with metabolic acidosis and anxiety.

  • Bradypnoea is defined as a respiratory rate of less than 10 breaths/min. It is an uncommon finding, and is usually due to central nervous system depression by narcotics or trauma.

Observation (Or) Inspection

  • Examination starts by observing the patient

  • General appearance-can be noted while introducing yourself to the patient.

  • Body type

  • Body weight - Weight is often recorded on the observation chart.

  • Height: Body mass index (BMI): dividing the weight in kilograms by the square of the height in metres (kg/m2kg/m^2) normal range is 20-25 kg/m2kg/m^2.

    • Below 20 are underweight

    • 25-30 are overweight

    • Over 30 are classified as obese

  • Respiratory function can be compromised by both obesity and severe malnourishment.

  • Malnourished patients often exhibit depression of their immune system with increased risk of infection. They also have weaker respiratory muscles which are more likely to fatigue

  • Obesity causes an increase in residual volume (RV) and a decrease in functional residual capacity (FRC) postoperatively, obese are more prone to subsegmental lung collapse.

  • An accurate daily weight gives a good estimate of fluid volume changes, as any change in weight of more than 250 g/day is usually due to fluid accumulation or loss. Daily weights are commonly used in intensive care, renal and cardiac patients to assess fluid balance.

  • In the intensive care patient there are a number of further features to be observed.

    • level of ventilatory support

    • Mode of ventilation ( IPPV,CPAP)

    • route of ventilation (mask, endotracheal tube, tracheostomy)

    • level of cardiovascular support including drugs to control blood pressure and cardiac output

    • pacemakers and other mechanical devices

    • level of consciousness (Glasgow Coma Scale)

  • Measures of central venous pressure (CVP), pulmonary artery pressure (PAP), and intracranial pressure (ICP) will need to be reviewed as part of the physiotherapy assessment.

  • lines and tubes going into and coming out of the patient should be noted.

    • Venous lines

    • Central venous lines

    • arterial line

    • cardiac pacing wires

    • Intercostal drains

    • Nasogastric tubes

Specific Observation

  • Observation of the Head

    • The eyes

      • pallor (anaemia), plethora (high haemoglobin)

      • Jaundice (yellow colour due to liver or blood disturbances)

    • Eyelid –ptosis

      • Drooping of one eyelid with enlargement of that pupil suggests Horner's syndrome where there is a disturbance in the sympathetic nerve supply to that side of the head (sometimes seen in cancer of the lung)

    • Nose –nasal flaring

    • Mouth- Central cyanosis, seen on examination of the tongue and mouth

    • Lips-Pursed lip breathing, and cyanosis

  • Cyanosis

    • It is a bluish discolouration of the skin and mucous membranes

    • Central cyanosis, seen on examination of the tongue and mouth is caused by hypoxaemia where there is an increase in the amount of haemoglobin not bound to oxygen.

    • The degree of blueness is related to the quantity of unbound haemoglobin.

    • Thus a greater degree of hypoxia is necessary to produce cyanosis in an anaemic patient (low haemoglobin), whilst a patient with polycythaemia (increased haemoglobin) may appear cyanosed with only a small drop in oxygen levels

    • Peripheral cyanosis, affecting the toes, fingers and earlobes may also be due to poor peripheral circulation, especially in cold weather.

  • Observation of the Neck

    • Position of trachea: midline/right/left

    • Trail sign

    • Tracheal tug or oliver sign

    • Jugular venous pressure:normal/increased/ markedly increased( Normal is 6 to 8 cm H2O)

    • Use of accessory muscles- SCM/PM/Tr

    • Prominence of accessory muscles

  • Jugular venous pressure

    • On the side of the neck the jugular venous pressure (JVP) is seen as a flickering impulse in the jugular vein

    • It is normally seen at the base of the neck when the patient is lying back at 45°

    • The JVP is usually measured in relation to the sternal angle as this point is relatively fixed in relation to the right atrium.

    • A normal JVP at the base of the neck corresponds to a vertical height approximately 3-4 cm above the sternal angle

    • The JVP is generally expressed as the vertical height (in centimetres) above norms].

    • The JVP provides a quick assessment of the volume of blood in the great vessels entering the heart.

    • Most commonly it is elevated in right heart failure. This may occur in patients with chronic lung disease complicated by cor pulmonale.

    • In contrast dehydrated patients may only have a visible JVP when lying flat.

    • Observation of the chest

      • Chest shape

        • symmetrical

        • The transverse diameter should be greater than the anteroposterior (AP) diameter

        • the ribs join normal 45° angle with the thoracic spine

        • The thoracic spine should have a slight kyphosis

  • Important common abnormalities include:

    • Kyphosis, where the normal flexion of the thoracic spine is increased.

    • Kyphoscoliosis, which comprises both lateral curvature of the spine with vertebral rotation (scoliosis) and an element of kyphosis. This causes a restrictive lung defect which, when severe, may cause respiratory failure

    • Pectus excavatum,or 'funnel' chest, is where part of the sternum is depressed inwards. This rarely causes significant changes in lung function but may be corrected surgically for cosmetic reasons.

    • Pectus carinatum, or 'pigeon chest, is where the sternum protrudes anteriorly This may be present in children with severe asthma and rarely causes significant lung function abnormalities.

    • Hyperinflation, where the ribs lose their normal 45° angle with the thoracic spine and become almost horizontal. The anteroposterior diameter of the chest increases to almost equal the transverse diameter. This is commonly seen in severe emphysema.

  • Breathing pattern

    • Normal breathing should be regular with a rate of 12-16 breaths /min.

    • Inspiration is active and expiration passive.

    • The approximate ratio of inspiratory to expiratory time ( I : E ratio) is 1:1.5 to 1:2.

    • Thoraco abdominal/abdomino thoracic

    • Prolonged expiration may be seen in patients with obstructive lung disease, where expiratoryairflow is severely limited by dynamic closure of the smaller airways. In severe obstruction the I: £ ratio may increase to 1:3 or 1:4.

    • Pursed-lip breathing is often seen in patients with severe airways disease. By opposing the lips during expiration the airway pressure inside the chest is maintained, preventing the floppy airways from collapsing. Thus overall airflow is increased.

    • Apnoea is the absence of breathing for more than 15 seconds. Hypopnoea is diminished breathing with inadequate ventilation. It may be seen during sleep in patients with lung disease

    • Kussmaul's respiration is rapid, deep breathing with a high minute ventilation. It is usually seen in patients with metabolic acidosis.

    • Cheyne Stokes respiration refers to irregular breathing with cycles consisting of a few relatively deep breaths, progressively shallower breaths (sometimes to the point of apnoea), and then slowly increasing depth of breaths. This is usually associated with heart failure, severe neurological disturbances, or drugs (e.g. narcotics).

    • Ataxic breathing consists of haphazard, uncoordinated deep and shallow breams. This may be found in patients with cerebellar disease.

    • Apneustic breathing is characterized by prolonged inspiration, and is usually the result of brain damage.

  • Chest movement

    • During normal inspiration, there are symmetrical increases in the anteroposterior, transverse and vertical diameters of the chest.

      • vertical diameter- contraction of the diaphragm

      • Sternal and rib movements are responsible for the increases in anteroposterior and transverse diameters of the chest 'pump handle‘ movement sternum 'bucket handle‘ movement of ribs

    • When breathing is increased, all the accessory inspiratory muscles (sternomastoid, scalenes, trapezii) contract to increase the anteroposterior and transverse diameters, and the diaphragm activity increases, thus further increasing the vertical dimensions.

    • Expiration may become active with contraction of the abdominal and internal intercostal muscles.

    • Intercostal indrawing occurs where the skin between the ribs is drawn inwards during inspiration. It may be seen in patients with severe inspiratory airflow resistance. Larger negative pressures during inspiration suck the soft tissues inwards. This is an important sign of respiratory distress in children, but is less often seen in adults.

      • Supra clavicular indrawing

      • Sub costal indrawing

  • Clubbing

    • It is the term used to describe the changes in the fingers and toes, clubbing is the loss of the angle between