1. History and Physical Examination
Chapter 1
History and Physical Examination

2. Objectives
Discuss the factors essential in the creation of a therapeutic climate.
Explain three considerations of an effective health history.
Explain the relevance of cultural diversity in the history-taking process.
List the major components of a health history.
Identify the four major examination techniques.

3. Objectives
Define common terms used in assessment of the respiratory system.
Explain the technique for auscultation of the chest.
Define terms associated with normal and abnormal breath sounds.
List the signs associated with respiratory distress.
Identify common pathologic processes of the respiratory system and pertinent physical findings that extend to other body systems.

4. Objectives Identify the significance of various chest landmarks.
Explain the significance of sounds heard during cardiac auscultation.
Explain the significance of jugular venous distention.
Explain common findings associated with an assessment of the neurologic system.

5. Creating a Therapeutic Climate
To ensure a therapeutic, professional relationship, competence and caring must coexist.
Variables supporting a therapeutic climate:
Caring demeanor
Competence
Eye contact
Judicious use of touch
Professional image

6. Components of the Health History
Chief complaint
History of present illness
Occupational and environmental history
Geographic exposure
Activities of daily living
Smoking history
Cough and sputum production
Family and medical history
Review of systems

7. History of Present Illness
Onset
Location
Duration
Character
Associated Manifestations
Relieving factors
Treatment

8. Stop and Think
You are seeing a patient for the first time. You are told that the patient has COPD.
What information would you collect regarding the patient’s health history?

9. Vital Signs Vital signs are:
Pulse
Respirations
Blood pressure
Normal body temperature is 37° C (98.6° F).

10. Age-Specific Angle
Compared with adults, infants and children have higher respiratory rates, higher pulse rates, and lower blood pressure readings.

11. Techniques of Assessment
Respiratory assessment techniques include:
Inspection
Palpation
Percussion
Auscultation

12. Percussion Technique
© Jones & Bartlett Learning. Courtesy of MIEMSS.

13. Percussion Notes
Flat
Dull
Resonant
Hyperresonant
Tympanic

15. Stethoscope (Diaphragm and Bell)
© Martin Kubát/ShutterStock, Inc.

16. Physical Examination of the Lungs and Thorax
The clinician must be thoroughly familiar with human anatomy and have an in-depth knowledge of structure and function to assess findings of underlying pathologic processes.

17. Thoracic Landmarks

18. Topographic Landmarks of the Chest
Anterior Thorax

19. Surface Anatomy of the Thorax

20. Breathing Patterns Tachypnea Orthopnea Hyperpnea
Paroxysmal nocturnal dyspnea
Kussmaul respirations
Cheyne-Stokes respirations
Bradypnea
Dyspnea
Biot’s respirations
Platypnea

21. Patterns of Respiration
Reproduced from Mosby’s Guide to Physical Examination, Seidel HM, Ball JW, Dains JE, et al., Copyright Elsevier [Mosby] 1999.

22. Physical Examination of the Lungs and Thorax
Flail chest is the appearance of a thorax with multiple rib fractures, causing instability of the chest wall.
Flail chest with paradoxical respiration indicates a serious injury.
Nasal flaring
Pursed lip breathing
Use of accessory muscles

23. Chest Wall Abnormalities
Barrel chest
Pectus excavatum
Pectus carinatum
Scoliosis
Kyphosis

24. Barrel Chest

25. Pectus Excavatum
(Left) © Custom Medical Stock Photo; (right) © M. English, MD/Custom Medical Stock Photo.

26. Scoliosis
Courtesy of Darci Manley

27. Kyphosis
(Left) © Dr. P. Marazzi/SPL/Science Source; (right) © Apogee/Science Source

28. Lordosis
(left) © Wellcome Trust Library/Custom Medical Stock Photo; (right) © medicalpicture/Alamy Images.

29. Physical Examination of the Lungs and Thorax
Skin color may indicate:
Cyanosis
Pallor
Plethora
Jaundice
Use of accessory muscles may indicate increased work of breathing.

30. Physical Examination of the Lungs and Thorax
Those in respiratory distress commonly exhibit nasal flaring.
Those with emphysema may use pursed lip breathing to maintain airway patency and better expiratory flow.

31. Physical Examination of the Lungs and Thorax
Subcutaneous emphysema is the presence of air in the subcutaneous tissues of the neck, chest, and face.
The assessment of respiratory expansion is used primarily to determine whether the lungs are expanding symmetrically.
Tactile fremitus is defined as the palpation of vibrations of the chest wall as a patient speaks.

32. Stop and Think
Before initiating a respiratory care plan, you are assessing a patient with a history of COPD.
The patient is thought to have pneumonia precipitating an exacerbation.
What are your considerations when performing a physical assessment?

33. Clubbing Clubbing of the finger Normal digit
(A) © Biophoto Associates/Science Source; (B) © Jorge Salcedo/ShutterStock, Inc.

34. Clubbing Lung tumors Bronchiectasis Cystic fibrosis
Congenital heart disease
Liver and gastrointestinal disease
Hereditary
Not COPD

35. Measuring Diaphragmatic Excursion

36. Age-Specific Angle Stridor is associated with croup in children.
Grunting is associated with respiratory distress in the newborn.

37. Auscultation Intensity of breath sounds
Presence of bronchial breath sounds
Presence of adventitious breath sounds: crackles, rhonchi, wheezes, stridor, pleural friction rubs

39. Sequence of Auscultation from the Posterior View

40. Sequence of Auscultation from the Right Lateral View

41. Sequence of Auscultation from the Left Lateral View

42. Sequence of Auscultation from the Anterior View

43. Breath Sounds Noted in the Ill and Well Patient

44. Auscultation Intensity of breath sounds Presence of breath sounds
Presence of adventitious breath sounds: crackles, rhonchi, wheezes, stridor, pleural friction rub
Symmetry of breath sounds
Bronchophony, egophony, and whispered pectoriloquy

46. Patient Assessment
A patient presents with nasal flaring, coughing with a large amount of sputum production present, vital signs are stable, cyanosis is present. What other key factors are missing from your assessment?

47. Assessment of Heart and Blood Vessels
Precordium is the chest wall over the heart.
Heart sounds include notations of rate and rhythm, extra heart sounds, and murmurs.

48. Areas for Auscultation of the Heart

49. Cardiac Auscultation
Heart rate and rhythm
Extra sounds
Murmurs

50. Palpation of the Apical Pulse

51. Jugular Venous Distention

52. The Neurologic System
Glasgow Coma Scale used for an alteration in the level of consciousness because of trauma or some other hypoxic or metabolic event
Other indications of neurologic integrity are normality and equality of strength in all extremities.

56. CAM ICU
Reproduced from Guenther U, Popp J, Koecher L, et al. Validity and reliability of the CAM-ICU flowsheet to diagnose delirium in surgical ICU patients. Crit Care. 2010;25:144–156. Copyright 2010, with permission of Elsevier.

57. Decorticate Posturing

58. Decerebrate Posturing

59. Dilated Pupils

60. Constricted Pupils

61. Unequal Pupils

62. Key Points
The health history provides a detailed, chronologic record of the patient.
The HPI offers a description of the onset of the problem including whether it developed suddenly.
The 4 exam techniques commonly used are inspection, palpation, percussion and ausultaion.

63. Key Points Accessory muscle use implies increased work of breathing.
Respiratory expansion assessment helps determine if the lungs are expanding symmetrically.
Auscultation of chest allows assessment of adventitious breath sounds.

64. Key Points
Auscultation of heart sounds includes notations of rate and rhythm, extra heart sounds, and murmurs.
Glasgow Coma Scale is used to assess the level of consciousness.
The level of sedation in critically ill, mechanically ventilated patients the Ramsey score or the Richmond Agitation Sedation Scale is used.
Delirium is measured with the CAM score.