The Physical Exam What you’ll be doing in Lab

Pulse One of the first physiological “vital” signs ever taken in humans. When the heart pumps, sends a surge of blood through your vessels. This pressure wave can be felt as a small push on the outside. Since it is one wave for each cardiac contraction, the pulse is a convenient way to determine a person’s heart rate at any given point in time. A “normal” resting heart rate is said to be 60 beats per minute. Slightly built people (or people in EXCELLENT physical shape with little body fat) will have lower intrinsic resting rates, and heavier people will have higher intrinsic resting rates. Resting rates much over 90 bpm or much under 40 bpm indicate a problem. Since in some patients it will be hard to find a “radial” pulse (a pulse from the radial artery in the wrist) it is also good to know how to find a carotid pulse (from the carotid artery). When taking pulses, make sure that you never use your thumb. It has its own pulse, and you may be reading your own rate.

Radial Pulse Gently grasp the patient’s hand and place your index and middle finger on the bottom side of the patient’s wrist, half way between the midline and outer edge on the thumb side. If you don’t immediately feel a pulse, adjust your finger position slightly. If you still don’t feel a pulse, it may be necessary for you to press slightly and carefully on the patient’s wrist and slowly roll their skin one way and then the other until you find the pulse. If you are still unsuccessful in finding a pulse, you will have to try and find a carotid pulse.

Carotid Pulse Find the area of the patients larynx (Adam’s Apple). Gently place your index and middle finger on the patients throat about halfway between the larynx and the side of the throat (just in front of the muscle on the side of the neck). Gently push you fingers into the depression you will find there. If you don’t immediately feel a pulse, adjust your finger position and pressure until you find a pulse. Remember you can always try both sides of the body for the pulse.

More about Pulses Now, you need a watch with a second hand to count beats. Pulse rates are given in terms of beats per minute, but often you won’t find nurses taking your pulse for a whole minute. They generally go for 30 seconds and multiply by 2 or for 15 seconds and multiply by 4. Of course the down and dirty way to get a quick pulse is to go for 6 seconds and multiply by 10.

Blood Pressure Because there is a volume of blood in the vascular system, there exists a certain resting pressure against the vessel walls. When the heart pumps this standing blood, the pressure against the walls of the vessels increases. When the heart contracts it is said to be in systole. Thus, the systolic pressure, the higher of the two numbers, is the pressure when the heart is pumping. When the heart is at rest, it is said to be in diastole, so the diastolic pressure, the lower of the two numbers, is the pressure when the heart is at rest. Normal blood pressure is said to be 120mmHg/80mmHg.

How to take a BP 1.Put the cuff in the proper position on the patient (the arm is supported, and loose). 2.Place the diaphragm of the stethoscope in the proper position and hold it with one hand. 3.Pump up the cuff to about 160 mmHg and listen. (You should hear nothing) 4.Slowly let the air out until you start to hear a pulse. 5.On the first pulse you hear, write down the number indicated on the gage. This is the systolic pressure. 6.Slowly let out more air and listen. You will continue to hear pulses for a bit. They will begin to fade and then stop. 7.When you hear the last pulse, write down the number indicated by the needle. This is the diastolic pressure. 8.Let the remainder of the air out of the cuff, and take it off the patient. 9.Let the patient know the results.

Lung Sounds The inner surfaces of your lungs must be kept moist in order to support gas exchange. Also you have a mucous “train” that carries inhaled particulates out of your lungs. Different disorders can cause our lungs to have too much fluid in them such that your breathing passages get blocked. General Considerations Ideally the patient should be sitting on the end of an exam table. The examination room must be quiet to perform adequate auscultation. Observe the patient for general signs of respiratory disease (finger clubbing, cyanosis, air hunger, etc.). Try to visualize the underlying anatomy as you examine the patient.

Lungs cont’d Inspection Observe the rate, rhythm, depth, and effort of breathing. Note whether the expiratory phase is prolonged. Listen for obvious abnormal sounds with breathing such as wheezes. Observe for retractions and use of accessory muscles (sternomastoids, abdominals). Observe the chest for asymmetry, deformity, or increased anterior- posterior (AP) diameter. Confirm that the trachea is near the midline? Auscultation Use the diaphragm of the stethoscope to auscultate breath sounds. Posterior Chest Auscultate from side to side and top to bottom using the pattern shown in the illustration. Omit the areas covered by the scapulae. Ask the patient to breathe deeply. Compare one side to the other looking for asymmetry. Note the location and quality of the sounds you hear.

Lungs cont’d Adventitious (Extra) Lung Sounds Crackles These are high pitched, discontinuous sounds similar to the sound produced by rubbing your hair between your fingers. (Also known as Rales) Wheezes These are generally high pitched and "musical" in quality. Stridor is an inspiratory wheeze associated with upper airway obstruction (croup). Rhonchi These often have a "snoring" or "gurgling" quality. Any extra sound that is not a crackle or a wheeze is probably a rhonchi. Interpretation Breath sounds are produced by turbulent air flow. They are categorized by the size of the airways that transmit them to the chest wall (and your stethoscope). The general rule is, the larger the airway, the louder and higher pitched the sound. Breath sounds are decreased when normal lung is displaced by air (emphysema or pneumothorax) or fluid (pleural effusion). Extra sounds that originate in the lungs and airways are referred to as "adventitious" and are always abnormal (but not always significant). (See Table)

Heart Sounds When doctors hold the stethoscope to your chest, and tell you to breathe normally, they are listening to your heart. The normal opening and closing of the valves in your heart make sounds. A normal heart makes what we call a “Lub-Dub” sound. The “Lub” is the sound of the valves closing as the blood moves from the Atria of your heart to the Ventricles of your heart (this should be the loudest heart sound), and the “Dub is sound of the valves closing as the blood leaves the Ventricles of your heart and either goes to your lungs or your body. If there is a problem with the valves closing other sounds may be evident such as a “swish” or a “squeak”. These are classified as heart murmurs. As you have sets of valves on both the left and right sides of your heart, you should listen to both sides carefully and report the presence of a murmur on a given side.

Heart Ascultation Auscultation 1.Position the patient supine with the head of the table slightly elevated. 2.Always examine from the patient's right side. A quiet room is essential. 3.Listen with the diaphragm at the right 2nd interspace near the sternum (aortic area). 4.Listen with the diaphragm at the left 2nd interspace near the sternum (pulmonic area). 5.Listen with the diaphragm at the left 3rd, 4th, and 5th interspaces near the sternum (tricuspid area). 6.Listen with the diaphragm at the apex (mitral area). 7.Listen with the bell at the apex. 8.Listen with the bell at the left 4th and 5th interspace near the sternum.

Oral Temperature We will be taking our patient’s temperature sublingually (under the tongue). There are many ways to take temperatures now, so know what equipment you have.