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170 Cards in this Set
- Front
- Back
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aphasia
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the impairment of language that affects the production or understanding of speech and the ability to read or write
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ascites
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abnormal accumulation of fluid in the peritoneal cavity
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auscultation
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- the method of listening to sounds within the body with a stethoscope
- the body generates a variety of high- and low-frequency sounds both normal and abnormal - bowel and lung sounds |
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bruit
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- an abnormal "whoosh"-like sound of turbulent blood flow moving through a narrowed artery
- most significant in the carotid arteries |
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crepitus
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- crackling, grating, or grinding that is often felt or heard when two ends of bune rub togther
- palpable fractures |
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cyanosis
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- a bluish-gray skin color that is caused by reduced levels of oxygen in the blood
- indicates a relative lack of oxygen perfusion, although the number of red blood cells may be adequate to carry any available oxygen - correlates extremely well with low arterial oxygen saturation - can be visualized generally in the skin, but mostly in the fingernail beds, face and lips - commonly seen in states of oxygen desaturation or hypothermia, especially in young patients |
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delirium
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change in mental status that is marked by the inability to focus, think logically, and maintain attention
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dementia
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the slow onset of progressive disorientation, shortened attention span, and loss of cognitive function
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dermatomes
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distinct areas of skin that correspond to specific spinal or cranial nerve levels where sensory nerves enter the CNS
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ecchymosis
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- localized bruising or blood collection within or under the skin
- evaluate large areas for the possibility of underlying soft-tissue, bony or organ injury - serious wounds to the head, neck and torso and any evidence of potential hemorrhage should also be noted |
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foramen magnum
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- a large opening at the base of the skull
- the brain connects to the spinal cord through this |
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Glasgow Coma Scale
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soring system used to determine level of consciousness
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guarding
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contraction of the abdominal muscles in patients
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hernia
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protrusion of any organ through and opening into a body cavity where it does not belong
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inspection
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- looking at the patient, either in general or at a specific area (ie, a patient's overall appearance from the doorway, versus looking specifically at the chest wall for abnormalities/deformities)
- looking at the patient, either in general or at a specific area |
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Korotkoff sounds
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- sounds related to blood pressure that are heard by stethoscope
- are detected while listening to a patient's bp |
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syphosis
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outward curve of the lumbar spine just above the buttocks, and exaggerated form of lordosis results in the condition known as swayback
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mottling
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- a blotchy pattern on the skin , a typical finding in states of severe protracted hypoperfusion and shock
- readily evident in pediatric patients |
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murmur
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- an abnormal "whoosh"-like sound heard over the heart that indicates turbulent blood flow around a cardiac valve
- they are graded by the range of intensity (1) the softest and (6) the loudest - many people have normal, physiologic murmurs - in some patients they can represent pathology, depending on the underlying problem and anatomy of the valve involved |
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occiput
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the most posterior portion of the cranium
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ophthalmoscope
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- an instrument used to look into a patient's eyes and view the retina and aqueous fluid, consists of a concave mirror and a battery-powered light that is usually contained in the handle
- used to look into a patient's eyes and view the retina and aqueous fluid - the care provider looks through a monocular eyepiece that has rotating lenses (adjusts for depth and magnification) - reserved for hospital and physician use |
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otoscope
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- a tool used to view the ears of a patient, consists of a head and a handle, the head contains an electric light source and a low-power magnifying lens
- has an attachment for a disposable plastic earpiece (speculum) - examiner inserts the speculum into the ear and looks through a lens on the rear of the headpiece - most have a bulb to push air into the ear canal so they can view the movement of the tympanic membrane |
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pallor
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- paleness
- present when red blood cell perfusion to the capillary beds of the skin is poor - can also be detected by looking at the patient's lips or eye conjunctiva |
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palpation
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- physical touching of the purpose of obtaining information
- example - tenderness (elicited pain), deformity, crepitance, mass effect, pulse quality, and abnormal organ enlargement |
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parasthesias
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tingling or sensory change
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pathologic fracture
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a fracture that occurs when normal forces are applied to abnormal bone structures
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percussion
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- gently striking the surface of the body, typically overlying various body cavities to detect changes in the densities of the underlying structures
- allows paramedics to detect changes in the densities of the underlying structures - example - sounds over lung - medium to loud, low-pitched, resonant sounds - sounds over muscle and bone - soft, high-pitched, and flat - sounds over hollow organs (intestines) - loud, high-pitched, and tympanic |
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perfusion
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- the circulation of blood within an organ or tissue in adequate amounts to meet the cells' needs
- examination of perfusion is best accomplished by examining areas where the epidermis is the thinnest (fingernails, lips, and conjunctivae) - also the palms and the soles |
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physical examination
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- the process by which quantifiable, objective (based on fact or observable) information is obtained from a patient about his or her overall state of health
- compared with subjective (observed or perceived by the patient), historical information that is obtained from the patient - together they provide a comprehensive assessment of the patient - consists of two elements - obtaining vital signs and performing a head-to-toe survey - done in a sequential way |
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physiologic fracture
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a fracture that occurs when abnormal forces are applied to normal bone structures
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primative reflexes
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reflex reactions such as Babinski, grasping, and sucking signs normally found in very young patients
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pulse oximetry
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- an assessment tool that measures oxygen saturation of hemoglobin in the capillary beds
- should never be an absolute indicator - treat your patient not your instrument - can be inaccurate - a hypotensive or cold patient, CO poisoning, abnormal hemoglobin (sickle-cell disease), vascular dyes, patient motion, incorrect placement |
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rales
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rattling, bubbling, or crackling lungs sounds
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reflexes
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involuntary motor responses to specific sensory sensory stimuli, such as a tap on the knee or stroking the eyelash
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rhonchi
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- lung sounds that resemble snoring
- low wheezes |
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rubor
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redness, one of the classic signs of inflammation
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rubs
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- lung sound produced by a partial loss of intrapleural integrity when an abnormal collection of fluid has accumulated between a portion of the visceral and parietal pleura, resulting in "pleuritic" pain and a perceived rub on auscultation
- can be heard emanating from either the lungs or the heart - produced by a parital loss of intrapleural integrity - when an abnormal collection of fluid has accumulated between a portion of the visceral and parietal pleura - result in pleuritic pain and perceived rub on auscultation |
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scoliosis
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sideways curvature of the spine
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stridor
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- a harsh, high-pitched, corwin inspiratory sound, such as the sound often heard in acute laryngeal obstruction
- abnormal respiratory sound of the upper airway that is often apparent, can also be auscultated |
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tenting
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- a condition in which the skin slowly retracts after being pinched a pulled away slightly from the body, a sign of dehydration
- is evident in extreme cases, especially in young children |
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turgor
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- loss of elasticity in the skin
- relates directly to hydration - turgor is insignificant in older patients because of normal changes in elastin and connective tissues, and also patients with abnormally dry skin |
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vasoconstriction
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- narrowing of a blood vessel, such as with hypoperfusion or cold extremities
- patient may have pale skin, which can indicate severe vasoconstriction - seen in profound anemia, acute cardiovascular events, shock-like states, and hypothermia - blanched, cool, white skin are typical in frostbite |
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vasodilatation
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- widening of a blood vessel
- reddening or pink skin (flushing) - apparent in patients with fever, allergic process, and superficial burns |
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visual acuity (VA)
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- the ability or inability to see, and how well one can see
- check VA by examining each eye in isolation - check VA with correction in place - can use a Snellen (E) chart - other tests include: light/dark discrimination and finger counting - distances 6', 3' and 1' should be noted for finger counting |
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exam techniques
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- inspection
- palpation - percussion - auscultation - allows paramedic to use their physical senses to obtain physical info and to understand the normal (versus abnormal) functions of a patient's body |
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vital signs
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- consists of a measurement of pulse rate - rhythm and quality, respiratory rate - rhythm and quality, blood pressure, temperature and pulse oximetery
- most basic objective data for determing patient status - can vary with age, medication use, and physical and mental conditions - requires auscultation, palpation and inspection - should be checked frequently |
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stethoscope
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- consist of a bell and diaphragm
- bell is used for deep and low-pitched sounds (heart), placed lightly on the skin - diaphragm is used for high-pitched sounds (breath, bowel, and normal heart sounds), placed firmly on skin - can be acoustic or electronic, acoustic blocks out other noise, electronic converts acoustic sounds into an electronic signal and then amplifies it |
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blood pressure
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- measurement of force exerted against the walls of the blood vessels
- commonly measured in a peripheral artery, but can be obtained anywhere - a product of cardiac output and peripheral vascular resistance - includes systolic and diastolic pressure - can be increased by anxiety and stress (watch trends and patient) - can be measured using a cuff that is appropriate for the patient's size and build - too small or tight will measure too high - too large or too loose will measure too low - can be palpated to estimate systolic - avoid taking on a painful/injured extremity, or on the same side as an arm with arteriovenous shunt or fistula, or post-mastectomy side (can cause pain and inaccurate readings) |
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pulse
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- measurements should assess the rate, presence, location, quality, and rhythm
- palpation - gently compress and artery against a bony prominence (allows to feel the pressure wave generated by the heart's contraction) - can be obtained at the radial, brachial, femoral, and carotid - minimum of 15 secs and multiply by 4 - basic way to evaluate perfusion and cardiac output - should compare proximal and distal pulses - unresponsive patients - should be counted in the most peripheral location - responsive patient - check respirations at the same time - decreases the tendency for a patient to alter their breathing - infants - best to use the brachial if under 1 year |
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respiration
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- typically measured by inspection of the chest, but can be assessed by abdominal wall, neck, face, and accessory muscles
- quality of effort should be evaluated - should recognize pathologic respiratory patterns or rhythms - recognize breathing difficulties may exhibit tripod positioning, accessory muscle use, or retractions - especially in pediatrics - should be measured at a minimum of 30 secs and multiplied by 2. |
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temperature
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- many methods can be used
- tympanic devices - entrinsic factors can increase and decrease reading - treat your patient, not the instrument |
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systolic pressure
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- created by the left ventricle while it is contracting (ie, in systole)
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diastolic pressure
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- the result of residual pressure in the system while the left ventricle is relaxing (ie, in diastole)
- should normally not go to zero, because peripheral vascular resistance in the arteriolar side of the circulatory system should continually provide for a diastolic pressure - the coronary arteries receive blood flow by this mechanism - lower diastolic pressure means less myocardial perfusion |
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Equipment used to perform a physical exam
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- stethoscope
- blood pressure cuff (sphygmomanometer) - ophthalmoscope - otoscope - scissors - a reliable light source - gloves - sheet or blanket - |
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sphygmomanometer
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- blood pressure cuff
- used in the measurement of a patient's blood pressure - consists of an inflatable cuff, that occludes blood flow, and a manometer (pressure meter) that determines the pressure in the artery at various points - appropriate size must be used (1/2 to 2/3 the size of the upper arm) - BP is measured in mmHg |
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general impression
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- begins as you approach the scene
- size up the situation and the patient's overall presentation - helps to evaluate whether a patient is sick or not, right away - look for signs of distress - look for other aspects such as dress, hygiene, expression, overall size, posture, untoward odors, and overall state of health - quickest way is to look at the skin the skin's color, relative moisture and relative temperature |
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signs of distress
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- mental status changes
- anxiousness - labored breathing and difficultly speaking - diaphoresis - obvious pain or deformity - guarding - splinting of a painful area - it is not uncommon for patients with substantial pain to present with a quiet and still affect - use terms to describe: no apparent distress, mild (slight or not harsh), moderate (small or average), acute (very great or bad), and severe (dangerous or difficult to endure), chronically ill, frail, feeble, robust and vigorous |
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elements of a physical exam
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- mental status
- skin, hair and nails - head, ears, eyes, nose and throat - cervical spine - chest - cardiovascular system - abdomen - male/female genitalia, anus - musculoskeletal system - peripheral vascular system - spine, nervous system |
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mental status
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- assessing cognitive function (ability to reasoning or perception)
- evaluate their alertness - use the Ao x 4 method - classify them according to the best response you can elicit |
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AVPU
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Alert - oriented to person, place and day
Verbal Painful Unresponsive |
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mental status is children
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- may be difficult to evaluate
- determine if they are alert - infants should follow you with their eyes (tracking) - ask parents if they are normal - most children older than 2 years should now their names, and the names of their parents and siblings - to evaluate ask about holidays, recent school activities, teacher's names, etc |
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skin
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- the largest organ system in the body
- governs the body's thermoregulation - composed of the epidermis and the dermis - with age, comes the loss of collagen connective tissue and diminished capillary supply |
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3 major functions of the skin
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- regulates the temperature of the body
- transmits information form the environment to the brain - protects the body in the environment |
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thermoregulation in cold environments
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- the blood vessels constrict and shunt blood away from the skin to decrease the amount of heat radiated from the body surface
- observed as pale skin |
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thermoregulation in hot environments
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- the blood vessels dilate, and the skin becomes flushed and red, and heat radiates from the body surface
- sweat is secreted to the skin surface from the sweat glands - energy, in the form of body heat, is lost during evaporation and the body temperature falls |
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nerve endings in the skin
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- information from the environment is carried to the brain through a rich supply of sensory nerves that originate in the skin
- nerve endings (in the skin) are adapted to perceive and transmit info about heat, cold, pressure, pain, and position of body - will recognize changes in the environment - reacts to pleasure, pain, and pressure stimuli |
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epidermis
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- the outermost layer
- body's first line of defense - principal barrier against water, dust, microorganisms, and mechanical stress |
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dermis
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- a tough, highly elastic layer of connective tissues
- composed of collagen fibers, elastic fibers, mucopolysaccharide gel, and fibroblasts that secrete collagen, elastin, and ground substance - subdivided into the papillary dermis recticular layer |
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papillary dermis
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- the vasculature provides nutrients to the epidermis and aids in thermoregulation
- dilation of vessels increases the blood flow to the skin (allows heat to dissipate) - constriction of vessels result in the retention of heat |
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reticular layer
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- consists of dense, irregular connective tissue
- provides strength and elasticity |
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examination of the skin
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- involves the inspection and palpation
- pay attention to skin color, moisture, temperature, texture, turgor, and lesions - look for evidence of diminished perfusion (pallor, cyanosis, diaphoresis) - become familiar with abnormalities - always look out for signs of abuse (injuries with different stages of healing or pressure sores) |
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skin temperature
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- can help to make a clinical distinction between two dfferent complications
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signs of injury on the skin
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- skin lesions - can be evidence of serious internal injury
- take note of ecchymosis, palpable crepitus, and open wounds - watch for areas of the skin that are covered by clothes or devices - always visually inspect and manually palpate the pateint's back and expose body parts - be discrete when necessary |
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examination of hair
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- done by inspection and palpation
- note the quality, distribution and texture - note any recent changed in growth or loss - can indicate an underlying reason |
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examination of nails
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- can reveal many subtle findings
- examine the color, shape, texture, and absence or presence of lesions - should be firm and smooth - normal changes due to age include striations and color change |
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Beau's lines
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- transverse depressions in the nail inhibiting growth
- systemic illness, severe infection, or nail injury |
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Clubbing
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- the angle between the nail and the nail base approaches or exceeds 180 degrees
- flattening or enlargement of the fingertips is associated with chronic respiratory disease |
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psoriasis
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- pitting, discoloration, and subungual thickening of the nail
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Splinter hemorrhages
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- red or brown linear streaks in the nail bed
- bacterial endocarditis or trichonosis |
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Terry's nails
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- transverse white bands that covert he nail except for the distal tip
- cirrhosis |
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HEENT exam
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- head, ears, eyes, nose and throat
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examination of the head
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- divided into the cranium and the face
- feel it and visually inspect it - important in trauma and unresponsive patients and patients with mental changes - any external bleeding - hair should be separated and the clot irrigated (help to identify the source of bleeding) - evaluate for any deformity, step-off, or tenderness - observe general shape and contour |
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cranium
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- contains the brain
- occiput is the posterior portion - temporal regions are on the sides - parietal regions are between the temporal and the occiput - frontal region is the forehead - can feel the superficial temporal artery in the temporal region behind the ear - a layer of muscle fascia covers the skull - thick skin covers the cranium, usually bearing hair (scalp) - the meninges lies within the skull |
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skull in children
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- children younger than 18 months, routinely palpate the logic closure
- can serve as an indicator of hydration and intracranial pressure - fontanelle is usually open and flat - can bulge when crying, or can be pathologic in a quiet child - can sink in with severe dehydration |
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examination of the face
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- observe the color and moisture of the skin, expression, symmetry, and contour
- look for any swelling, injuries, or respiratory distress - use DCAP-BTLS |
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DCAP-BTLS
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- Deformities
- Contusions - Abrasions - Punctures/Penetrations - Burns - Tenderness - Lacerations - Swelling |
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Steps to examine/access head
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- visually inspect, look for DCAP-BTLS
- palpate top and back, be systematic - part the hair and examine the scalp - note any pain - palpate the face and look for DCAP-BTLS - pay attention to the condition of the skin, hair distribution and shape of face |
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arachnoid and pia mater
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- much thinner than the dura mater
- contain the blood vessels that nourish the brain and spinal cord |
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meninges
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- three distinct layers of tissue that suspend the brain and the spinal cord within the skull and the spinal canal
- includes the dura mater, the arachnoid and the pia mater |
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dura mater
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- the tough, fibrous, outer layer of tissue surrounds the brain
- resembles leather - forms a sac that contains the central nervous system (CNS), with a small opening through which the peripheral nerves exit |
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cerebralspinal fluid
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- CSF
- produced in a chamber inside the brain (third ventricle) - fills the space between the meninges and acts as a shock absorber |
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eyes
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- tremendously complex sensory organ
- they process light stimuli for the brain - the brain decodes light impulses presenting to the eyes and form a visual image - they are a critical link to the CNS - examiner can assess the function of the CNS - consists of anterior and posterior chambers |
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examination of the eyes
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- assess visual acuity (VA)
- examine the pupils - test for cranial nerve function with Z or H test - check the eyelids, lashes and tear ducts - look for foreign bodies, evidence of wounds, trauma and discharge - turn up the lids and inspect the conjuctivae and sclera - examine the globe of the cornea - the posterior chamber and retina |
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issues to ask about the eyes
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- pain
- redness - loss of vision - diplopia (double vision) - photophobia - blurring - discharge - corrective lens use |
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pupil
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- a circular opening in the center of the pigmented iris of the eye
- the diameter and reactivity to light reflect the brain's perfusion, oxygenation, and condition - normally round and equal size - serve as optical diaphragms that adjust their size depending on available light - normal light - midsize - less light - dilate to allow more light in eye - bright light - constrict, allow less light - protect sensitive receptor in the eye - pupils should react equally even when light is only introduced to one eye - pupil size is regulated by a series of continuous motor commands sent from the brain through oculomotor nerves (third cranial nerve) |
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assessing the pupils
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- check for size (in mm), shape and symmetry
- check for reaction to light (best in a darkened area) - ask patient to follow your finger in a Z or H pattern - eyes should move smoothly and symmetrically - examines peripheral vision and done in isolation |
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asymmetric pupils
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- anisocoria
- found in 20% of the population - may indicate a significant ocular or neurologic pathology (must be correlated with patient's presentation) - can be affected by topical medicines and substances |
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conjunctivae
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- it should be pink, not cyanotic, pale or overly reddened
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sclera
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- should be white, not jaundice or injected (red)
- painless subconjunctival hemorrhage is common but benign presentation |
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steps of an eye exam
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- exam the exterior of the eye for trauma or deformity
- ask the patient about pain, altered vision, discharge, or sensitivity to light - measure VA with finger counting at varying distances on each eye - exam pupils for size, shape and symmetry (should be equal) - test the pupils for their reaction to light - test for cranial nerve function - inspect the eyelids, lashes, and tear ducts for evidence of trauma, foreign bodies or discharge |
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eye exam with an ophthalmoscope
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- darken the environment
- ask the patient to look straight ahead and focus on a distant object - set the light on the lowest necessary setting - examine each eye with your corresponding hand - place scope to your eye, about 10-20" away from patient's at a 45 degree angle - retina will be a "red reflex" or bright orange glow - move toward the patient and adjust the lens as needed - locate a blood vessel and follow it back to the disk - inspect for the size, color and clarity of the disk - move nasally to view the macula - cataracts appear as an opaque black area against the red |
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ears
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- a sensory organ that is involved in hearing and sound perception
- also involved in balance control - consists of outer, middle and inner portions |
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external ear
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- consists of the pinna or auricle (the part on the outside) and the external auditory canal
- leads to the tympanic membrane or eardrum |
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middle ear
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- contains three small bones (hammer, anvil, and stirrup)
- move in response to sound waves hitting the eardrum - mechanism controls how we hear and differentiate sounds - connected to the nasal cavity by the Eustachian tube or internal auditory canal - connection permits equalization of pressurein the middle ear when external atmospheric pressure changes |
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inner ear
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- consists of bony chambers filled with fluid
- as the head moves, so does the fluid - fine nerve endings within the fluid send impulses to the brain - the impulses indicate the postion of the head and the rate of change in position |
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assessing the ears
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- check for new aberrationsin hearing perception and inspect and palpate for wounds, swelling, or drainage (pus, blood, CSF)
- the mastoid process is palpated posterior to the auricle is assessed for discoloration and tenderness (Battle's sign) - abnormalitiesof external canal and tympanic membrane are visualized by an otoscope |
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examining the ears with an otoscope
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- select an appropriate speculum and dim lights
- ensure that ear is free of foreign bodies - place hand on patient's head and grasp the auricle - move ear upward and back to best visualize the canal - instruct the patient not to move - turn the otoscope on and insert speculum into ear toward the nose, but not deeply - inspect canal for any lesions or discharge - visualize the eardrum for integrity and color - note signs of inflammation, swelling, discoloration |
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nose
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- a sensory organ involved with smell and taste
- also part of respiratory system - divided into two chambers by the nasal septum (made of cartilage) - each chamber contains three (superior, middle, and inferior) layers of bone (turbinates) covered with a moist lining |
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breathing
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- air moves through the nasal chambers and is humidified as it passes over the turbinates
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assessing the nose
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- assess it anteriorly and inferiorly
- look for evidence of asymmetry, deformity, wounds, foreign bodies, discharge or bleeding, and tenderness - note any respiratory distress - nasal flaring - look for color changes, symmetry, and abnormalities externally - nose should be firm and the nares clear - the column should be midline to the face - slight abnormalities are normal, but gross abnormalities should be noted - not any drainage or discharge (large amounts of mucus, blood, or CSF |
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assessment of the throat
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- include an evaluation of the mouth, pharynx and neck
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throat
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- used for respiration and digestion
- may need to assess for the presence of a foreign body or aspiration - always be prepared to suction |
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mouth
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- part of the assessment of hydration
- look at the lips, teeth, oral mucosa, and tongue - determine the patient has an airway - lips - should be pink and free of edema and irregularities - gums - should be pink, with no lesions or edema - tongue - should be midline, without swelling and moist - oropharynx - identify any discoloration or pustules (infection) - note any unusual odors - uvula - edema and redness |
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neck
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- extraordinarily muscular
- includes jaw, circothyroid membrane, external jugular veins, thryoid cartilage, suprasternal notch, cervical spinous processes |
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assessing the neck
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- look for symmetry, masses, and venous distention (consider patient's position)
- approximate the distension in cm - palpate the carotid pulse, note strength - look for pulsating or expanding mass near pulse - palpate suprasternal notch (identify any tracheal deviation) - have patient open and close jaws while you palpate the temporomandibular joint |
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steps to examine the neck
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- if trauma is suspected take c-spine
- assess for accessory muscle usage - palpate neck to find any abnormalities or subcutaneous air, tracheal deviation - start at suprasternal notch and work toward head - careful applying pressure to carotid arteries (could stimulate a vagal response) - assess lymph nodes and note any swelling (may indicate infection) - assess the jugular veins for distention (may indicate problem with blood returning to heart) |
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cervical spine
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- pathway where the spinal cord goes from the brain to the torso
- enables the spinal nerves to emanate to and innervate into the body - point where the heaad connects to the body - supported by a large mass of muscle, tendons and ligiments |
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cervical spine assessment
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- evaluate for multiple organ involvement (MOI) and then for pain
- evaluate mental status and LOC - is patient under the influence - inspect and palpate, looking for deformity or tenderness - midline posterior tenderness involving bony spinous processes should be concerning - discomfort over the lateral neck are usually muscular or ligment problems - any manipulations that result in pain, tenderness, or tingling - you should stop the exam and treat as a c-spine injury - anyone complaining of neck ain should be c-collared - first examine passively, then actively - range of motion (shoulder to shoulder, back and foward) - any discomfort, discontinue and protect spine |
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chest
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- consists of the superior aspect of the torso, from the neck to the diaphragm (costal arch)
- consists of many vital structures (lungs, heart and great vessels) |
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chest wall
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- divided into anterior and posterior portions
- serves as a protective covering for the internal components - consists of muscularskeletal, vascular, nervous, connective and lining structures |
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exam of the chest
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- three phases
- chest wall is checked, pulmonary evaluation and cardiovascular assessment - inspect for deformities and respiratory distress - expose chest and inspect, palpate, percuss, and auscultate both the back and front |
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steps to examine the chest
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- ensure privacy
- inspect for DCAP-BTLS - dress open wounds - note shape of chest - look for scars - palpate for subcutaneous air - auscultate the lungs - percuss chest - ausculate the heart - repeat on the other side |
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respiratory examination
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- document the rate, depth and rhythm
- watch for paradox, accessory muscle use, impaired and diminished breathing, retractions, deformities (barrel chest), flail segments, subcu air, trauma, bruising |
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exam of the chest wall
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- palpate and not any tenderness, crepitus
- feel for expansion and symmetry - percussion may distinguish abnormal or different resonance |
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auscultate the breath sounds
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- lungs have 5 discrete lobes
- right - upper, middle, lower - left - upper, lower, lingual - listen over each lobe, anteriorly and posteriorly - have patient take a deep breath - avoid any clothing or other barriers |
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emphysema
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- lungs are hyperinflated and result in hyperresonance instead of cardiac dullness
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normal lung sounds
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- include bronchial, vesicular, bronchovesicular sounds
- function of air passing through structure |
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pathologic lung sounds
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- or adventitious (added)
- includes wheezes, rales (or crackles) and rhonchi (low wheezes) - indications of lung tissue consolidation, atelectasis, edema, mucus collection or hemorrhage |
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decreased lung sounds
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- can be localized to a portion of one lung, or can encompass the entire chest
- must take immediate action - typically a signal of a lack of respiratory excursion or decreased tidal volume - can be caused by pneumothorax, hemothorax, pleural effusion, pulmonary edema, atelectasis/consolidation, exacerbated COPD, status asthmaticus, opiate intoxication, pneumonia, bronchitis, altered mental status - if you can see or hear the patient breathe, there is a problem |
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cardiovascular system
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- circulates blood throughout the body
- maintains perfusion of the body's tissues - comprises of a pump (the heart), a set of pipes (the blood vessels), and a liquid transported within the pipes (blood) - arteries, arterioles, capillaries, venules, and veins - entirely closed system |
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blood
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- consists of plasma, red blood cells, white blood cells, and platelets
- blood flows through systemic circulation in the body and pulmonary circulation in the lungs |
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plasma
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- is essentially a mild saline solution
- also contains blood-clotting factors and particles that play important role in the body's immune response |
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systemic circulation
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- carries oxygen-rich blood from the left ventricle through the body and back to the right atrium
- blood passes through the tissues and organs - it gives up oxygen and nutrients - absorbs cellular wastes and carbon dioxide - cellular wastes are eliminated as the blood flows through the liver and the kidneys |
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pulmonary circulation
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- carries oxygen-poor blood from the right ventricle through the lunds and back into the left atrium
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cardiac cycle
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- involves the relaxation (diastole), filling, and contraction (systole)
- are coordinated electrically with the heart's pacing and conduction system - coordinates the movement of blood between the chambers of the heart (atria contract and relax together, as do the ventricles) - while the atria are contracting (and filling the ventricles), the ventricles are relaxing - when the ventricles are contracting, the atria are relaxing and are being filled by either the vena cava or the pulmonary veins |
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heart
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- consists of four chambers
- two atria (upper chambers) - two ventricles (lower chambers) - each side of the heart contains one atrium and one ventricle - each atrium receives blood that is returned to the heart from other parts of the body - each ventricle pumps blood out of the heart |
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interatrial septum
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- a membrane that separates the two atria
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interventricular septum
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- a thicker wall that separates the two ventricles
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atrioventricular valves
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- separate the upper and lower portions of the heart
- prevent backward flow of blood |
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semilunar valves
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- located between the ventricles and the arteries into which they pump blood
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direction of the blood
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- blood enters the right atrium via the superior and inferior vena cavae and the coronary sinus
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coronary sinus
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- consists of veins that collect blood returning from the walls of the heart
- blood from four pulmonary veins enters the left atrium |
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fossa ovalis
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- a depression that represents the former location of the foramen ovale
- between the right and left atria |
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foramen ovale
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- an opening between the two atria that is present in the fetus
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characteristics of heart sounds
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- the contraction and relaxation of the heart, combined with the flow of blood generates heart sounds
- normal pattern is lub-DUB, lub-DUB, lub-DUB - lub is the first heart sound or S1 - DUB is the second heart sound or S2 |
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S3
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- usually a pathologic heart sound
- is the third heart sound and is a soft, low-pitched sound that occurs about one third of the way through diastole - it is sometimes present in healthy young people, but is abnormal in patients over 35 - is associated with abnormally increased filling pressures in the atria secondary to moderate to severe heart failure - "da" |
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S4
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- a pathologic heart sound, always abnormal
- considered a "gallop" rhythm - it is a moderately pitched sound that occurs immediately before the normal S1 sound - represents either decreased stretching (compliance) of the left ventricle or increased pressure in the atria - "bla" |
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steps to listening to heart sounds
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- place the patient - sitting up and leaning slightly forward, supine, or left lateral recumbent
- place stethoscope at the fifth intercostal space over the apex of the heart - to appreciate S1 - ask patient to breath normal and hold the breath on expiration - to appreciate S2 - ask patient to breath normal and hold breath on inhalation - for S3 and S4, listen avover the left nipple |
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arterial pulses
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- physical expression of the systolic blood pressure
- caused when contraction of the left ventricle and ejection of blood into the systemic circulation generate a pressure wave - travels throughout the arterial system - palpable wherever an artery crosses a bony prominence |
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venous pressure
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- tends to be very low
- normally, the pressure in the vena cava just before blood is received into the right atrium - close to zero |
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veins
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- are relatively nonmuscular, thin-walled vessels that have no effect on the systemic vascular resistance and do not assist in promoting systemic bp
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venous system
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- blood flows through the venous system and returns to the heart by being propelled from behind continuously (drains the capillary network)
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respiratory cycle
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- responsible for most venous return of blood
- generated by negative intrathoracic pressure that is developed by inspiration during normal breathing |
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JVD
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- jugular venous distention
- jugular venous pressure - can estimate the capacity of the venous system - in right-sided heart failure, blood tends not to be readily accepted into the right atrium - venous capacitance increases in an effort to compensate for this failure, this results in elevated pressures and corresponding JVD - can be most readily observed by evaluating the anterolateral aspects of the neck - can be provoked in a normal person by having the lie down and elevate their legs |
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examining for JVD
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- important to note how much distention is present (in cm) from the orign of the vein at the base of the neck
- note the angle relative to 0 degrees |
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hypotension and JVD
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- there may be no evidence of JVD, even when supine
- must be carefully assessed - may be experiencing cardiogenic shock or ruptured a cardiac valve - with chest trauma, may symbolize a pneumothorax or pericardial tamponade |
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circulatory vs. age
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- the ability for the circulatory system to constrict and dilate can diminish with age
- may very from patient to patient, but generaly older patients have more difficultly compensating - aterial atherosclerosis and diabetes, can affect this - many medications can negatively affect the body ability to handle sudden changes - young children and adults have an enhanced ability to vasoconstrict and increase the pulse rate to compensate for vascular insult |
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examination of the cardiovascular system
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- pay attention to arterial pulses - note location, rate, rhythm, and quality
- obtain accurate bp and repeat periodically - examine for JVD - inspect and palpate chest wall (locate the point of maximum impulse (PMI)) - listen for heart sounds and valve sounds - note the intensity of the heart sounds, and listen for S1, S2 and any extra sounds |
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aortic valve
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- found near the second intercostal space, to the right of the sternum
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pulmonic valve
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- lies near the second intercostal space, to the left of the sternum
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tricuspid valve
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- auscultated over the lower left sternal border
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mitral valve
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- over the cardiac apex, lateral to the lower left sternal border near the midclavicular line
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abdomen
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- contains all organs of digestion, the organs of the urogenital system and the significant neurovascular structures
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abdominal wall
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- relatively thick muscular organ that overlies the peritoneum
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peritoneum
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- a well-defined layer of fascia made up of the parietal and visceral peritoneum
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abdominal organs
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- either intraperitoneal or extraperitoneal
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intraperitoneal organs
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- include the stomach, proximal duodenum of the small intestine, pancreas, jejunum, ileum, appendix, cecum, transverse colon, sigmoid colon, proximal rectum, liver, gallbladder, spleen, omentum, and female internal genitalia
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extraperitoneal organs
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- include the mid- and distal duodenum, abdominal aorta, mid- and lower rectum, kidneys, pancreatic tail, adrenal glands, ureters, renal blood vessels, gonadal blood vessels, ascending colon, descending colon, and urinary bladder
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abdominal quadrants
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- umbilicus (central), diaphragm (top), and pelvis (bottom)
- LUQ, RUQ, LLQ, RLQ - RH - right hypochondrial - E - epigastric - LH - left hypochondrial - RL - right lumbar - U - umbilicus - LL - left lumbar - RI - right iliac - H - hypogastric - LI - left iliac |
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abdominal pain
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- common complaints, but often difficult to identify
- obtain any possible relevant info - historical info - location, quality, severity, time of onset and duration, significant activities at onset, any aggrevating or alleviating factors or associated symptoms (nausea, vomiting, febrile symptoms, changes in dietary, bowel or bladder habits) |
