Head to toe examination of pneumonia patient

The setting for the chest examination must be environmentally comfortable for both clinician and patient. The physical examination begins with the commencement of history taking. The examiner extends a hand in greeting, asks about the symptoms that initiated the visit, and begins physical inspection, noting body position, assessing degree of comfort, inspecting and palpating the hands, and noting grip strength. The history determines the examination format. Experienced clinicians exploit the history to help them "look" for specific physical findings to answer questions posed by the totality of data collected previously. When using this process, it is unusual for two consecutive chest examinations to be identical. By the time the physical examination is complete, even before laboratory evaluations are initiated, the diagnosis should be reasonably certain.

The pulmonary examination consists of inspection, palpation, percussion, and auscultation. The inspection process initiates and continues throughout the patient encounter. Palpation, confirmed by percussion, assesses for tenderness and degree of chest expansion. Auscultation, a more sensitive process, confirms earlier findings and may help to identify specific pathologic processes not previously recognized.

Inspection

Inspection () is an active process. It is done with the eyes and the intellect. It begins with the initial greeting and continues uninterruptedly during the entire data collection process. Even as the first serious question of the fully dressed patient is asked, the inspection begins through active observation. Specifically, one must note the dynamics of the patient's facial expression in relationship to physiologic activities (inspiration and expiration) and to the questions asked by the examiner. Similarly, active observation skills are used to search for the use of pursed lips during expiration, the activity and development of the sternocleidomastoid muscles, the use of other accessory muscles of ventilation, the presence of shoulder girdle fixation in relationship to the use of these accessory muscles, the flaring of the nasal alae, the presence of jugular venous distention, the degree of comfort, and, as discussed in previous chapters, the presence of cyanosis and clubbing. Not only may a voluntary smile be helpful in assessing neurologic function, but also inspection of the teeth at that time (even though you are just starting to take the history) may reveal extensive pyorrhea that serves to alert the clinician to a dental problem that has a potential as a bacterial source for necrotizing pneumonia.

As the interview continues, assessment of the level of consciousness and the appropriateness of behavior may lead one to suspect a primary pulmonary process that secondarily produces alterations of central nervous system function. Two examples are respiratory acidosis and cerebral metastases from primary carcinoma of the lung. Dress, too, may give a clue to occupation or hobby, grooming may be related to the conscientiousness with which the patient may follow a health care plan, and a bulging shirt pocket may be stuffed with an open package of cigarettes, an important clue to the possibility of a chest problem.

The inspection continues even though the patient remains fully clothed and the "formal" physical examination has not yet begun. It is often helpful to make an initial assessment of the ventilatory pattern early in the data collection process. Specifically, one should be concerned about rate, rhythm, breath volume, and the apparent effort associated with breathing. Most resting adults breathe about 12 times per minute, not the customary 20 often noted in medical records. Tidal volumes range around 600 ml. Except for an occasional sigh, the normal ventilatory pattern is regular and effortless. In disease this pattern may change.

The assessment of ventilatory pattern during the history does not give the patient an opportunity to alter breathing involuntarily and confound the data. It also allows one to process data earlier and to increase efficiency.

When the "formal" physical examination does begin, the setting is changed. Inspection continues, but with the patient undressed from the waist up, either entirely or sequentially, as drapes are changed to expose only those areas being actively observed. A chaperon should be present when it would make either the patient or the examiner more comfortable.

First, one should observe for thoracic cage deformity (pectus excavatum, pectus carinatum, scoliosis, kyphosis, surgical or traumatic scars, thoracoplasty, gynecomastia, and so-called barrel chest deformity). The presence of some skin lesions may reflect intrathoracic pathology. These are "static" observations. Even more useful information can be obtained as the patient breathes, both quietly and deeply. Such "dynamic" observations include the search for supraclavicular or intercostal retraction, paradoxical movement of the abdomen, any degree of asymmetry or asynchrony of chest expansion, muscle wasting or hypertrophy, and reproducible grimaces of discomfort at a given point in the ventilatory cycle. Other nonmanually elicited data such as audible musical breath sounds—wheezes—strongly influence the decision-making process.

Palpation

Palpation () is the next stage of the examination. With the patient disrobed, place the entire palm of each hand first on the superior portion of both hemithoraces and then, gently though firmly, move the hand inferiorly to just below the twelfth rib. Repeat the process moving laterally and subsequently anteriorly; search for rib deformities, nodules, and areas of tenderness. In the face of a history of chest discomfort, ask the patient to point to the area(s) of greatest discomfort. Palpate the area with increasing firmness in an attempt to elicit tenderness and to assess if this maneuver reproduces the patient's symptoms. Pay particular attention to the costochondral junctions in patients reporting anterior chest pain to evaluate the possibility of costochondritis.

Palpation is also important in the assessment of ventilation. One can sensitively assess the symmetry, synchrony, and volume of each breath. This is done by examining the patient posteriorly, placing the examiner's thumbs together at the midline at the level of the tenth rib with hands grasping the lateral rib cage; both visual and tactile observations are made both during tidal volume breathing and during deep forceful inhalation. With the latter, thumbs typically separate by approximately 2 to 3 cm.

A part of the palpatory portion of the chest examination is to assess the position of the trachea. This is accomplished best with the examiner stationed behind the patient, palpating the anterior inferior neck just above the jugular notch by gently pressing the fingertips between the lateral tracheal wall and the medial portion of the sternocleidomastoid muscle. Comparing one side to the other, an assessment is made of the position of the trachea: midline or deviation away from the centrist position.

Tactile appreciation of vibrations transmitted to the surface of the thorax as upper airways sounds are generated by breathing or speaking is a traditional though insensitive maneuver referred to as tactile or vocal fremitus. Egophony is both more specific and sensitive. It is discussed under auscultation.

Percussion

The purpose of percussion () is to determine if the area under the percussed finger is air filled (sounding resonant like a drum), fluid filled (a dull sound) or solid (a flat sound). To make this interpretation it is important not only to listen for the sound produced but also to feel the intensity and frequency of vibrations produced by this maneuver.

The technique of percussion is best accomplished by the following approach:

1. Press the distal phalanx of the middle finger firmly on the area to be percussed and raise the second and fourth fingers off the chest surface; otherwise, both sound and tactile vibrations will be blunted.

2. Use a quick, sharp wrist motion (like a catcher throwing a baseball to second base) to strike the finger in contact with the chest wall with the tip of the third finger of the other hand. The best percussion site is between the proximal and distal interphalangeal joints. The novice quickly learns to trim the fingernail to prevent personal discomfort of minor abrasions and lacerations.

3. If the sound and the vibrations produced seem suboptimal, make sure that the finger placed directly on the thorax is making very firm direct contact with the chest wall. If not, few vibrations and little sound will be produced.

4. Percuss the posterior, lateral, and anterior chest wall in such a manner that the long axis of the percussed finger is roughly parallel to the ribs. Compare one side to the other.

5. Over each area, begin percussion superiorly and extend inferiorly to identify the level of the diaphragm during quiet (tidal volume) breathing. Note the position of the diaphragm. Then ask the patient to inhale fully and "hold it"; continue to percuss inferiorly to determine the new level of the diaphragm, now during forced maximal inspiration. Then, don"t forget to tell the patient to "breathe normally." The difference between the two levels is known as diaphragmatic excursion and should equal 2 to 3 cm.

Auscultation

Auscultation of the chest () is part of every chest examination but it is the data collected during inspection, palpation, and percussion that alert the clinician what to listen for during auscultation in order to identify the correct diagnosis most effectively.

The stethoscope is an instrument that does not significantly amplify sound, but, more important, acts as a selective filter of sound. Briefly, the bell filters high-frequency sounds greater than 1500 cycles per second and therefore should be used to detect low-frequency sounds. On the other hand, the diaphragm selectively filters low-frequency sounds. Since sounds produced by breathing tend to be of relatively high pitch, the chest is ausculted with the diaphragm.

Auscultation of the chest ideally is performed in a quiet room with the patient either sitting or standing. When the posterior thorax is examined, the patient's arms should be crossed anteriorly to move the scapulas laterally as much as possible. Comparing one side to the other is a helpful maneuver to identify the patient's "normal." Auscultation should be performed during tidal ventilation, deep forceful inspiration, and forceful expiration. It is not only intuitively obvious but rigorously proved that the intensity of breath sounds is related to flow rates; that is, the louder the sound, the greater the flow rate, all other things being equal.

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