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Physical Exam Test #2

Study Guide
EXAMINATION OF THE CHEST AND LUNGS
1. Perform an examination of the chest and lungs.
2. Define terms relating to the chest and lungs.
3. Describe the clinical anatomy of the chest and lungs.

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Intercostal space
Apex of the lung, 2-4 cms above the
medial clavicles
Inferior border crosses 6th rib at MCL and
8th rib at MAL
Right horizontal fissure between the 4-5th
ICS at MAL

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Primarily the large lower lobes of the each lung


The lower lung border is at the level of 10th
spinous process
With deep inspiration the lower border descends
to 12th spinous process

4. List the characteristics of breath sounds and describe them.


Type
Duration
Intensity
Pitch
Vesicular
Inspiratory >
Soft
Low
expiratory
BronchoInspiratory =
Intermediate Intermediate
vesicular
expiratory
Bronchial
Tracheal

Expiratory >
inspiratory
Inspiratory =
expiratory

Locations
Over most of both lungs

Loud

High

1&2 interspaces
anteriorly; between
scapulae
Over manubrium

Very loud

High

Over trachea in neck

5. List the characteristics of the following types of breathing:


Tachypnea - persistent rate greater than 20/Min
Bradypnea - rate less than 12/Min; sleep may decrease it to 8/Min
Kussmal - deep and most often rapid breaths (metabolic acidosis)
Cheyne-Stokes - regular periodic pattern with intervals of apnea followed by a
crescendo/decrescendo sequence
Hyperventilation rapid, deep breathing
6. Describe the characteristics of the following types of breathing:
Tachypnea
Baradypnea
Kussmaul

Physical Exam Test #2


Study Guide
Cheyne stokes
Hyperventilation
7. List the characteristics of the following conditions and describe them:
Pectus carinatum (pigeon chest) sternum is displaced anteriorly, increasing the
anteroposterior diameter; costal cartilages adjacent to protruding sternum are
depressed
Pectus excavatum (funnel chest) depression in the lower portion of sternum;
compression of heart and great vessels may cause murmurs
Atelectasis lobar obstruction; affected lung tissue collapses from obstruction;
will note dullness on percussion and absence of breath sounds and tactile fremitus
Emphysema slowly progressive disease in which distal air spaces are enlarged
and lungs become hyperinflated; percussion will be hyperresonant; breath
sounds / tactle fremitus decreased
Pleural effusion fluid accumulation in pleural space; percusses dull over fluid;
breath sounds and tactile fremitus decreased to absent
Pneumothorax air leaks into pleural space; percussion is hyperresonant; air
blocks transmission of sound
Barrel chest increased anteroposterior diameter; associated w/ COPD
Thoracic kyphoscoliosis abnormal spinal curvatures and vertebral rotation
deform the chest; results in distortion of lungs
(know the other back curves)
8. List the steps in the examination of the chest and lungs.
9. Describe the steps in the examination of the chest and lungs.
Additional Information:
Retraction of interspaces during inspiration may be due to obstruction (stridor); bulging
of interspaces during expiration due to out-flow obstruction (aneurysm, tumor, CHF)
Visual inspection:
Pursing of the lips: (increased respiratory effort)
Cyanosis of the lips and/or nail beds
Clubbing of the nail beds: (COPD, CHF)
Flaring of the nares: air hunger (asthma)
Respitory rate and rhythm:
Normal adult = 14 to 20 unlabored breaths per minute
Normal child = 20 to 30 unlabored breaths per minute
As high as 44 breaths per min in a new born infant
Biot's respirations - respirations varying in depth and interrupted by intervals of apnea
but lacking repetitive pattern of periodic respirations
Platypnea- dyspnea which increases in upright posture (pericarditis)
Hyperpnea: deep breathing
Hypopnea: shallow breathing

Physical Exam Test #2


Study Guide
Percussion:
Flatness: soft, short and extremely dull (atelectasis, effusions)
Dullness: medium intensity, medium length, thud-like (pneumonia, mass)
Resonance: Loud, long and hollow, considered normal lung tissue sound
Tympany: loud, medium length and drum-like
Hyperresonance: Very loud, long, booming (air trapping, asthma, emphysema)
Special auscultation tests:
Whispered pectoriloquy - when whispered word is heard with great clarity.
Bronchophony - greater clarity and increased loudness of spoken sounds
Egophony - changes in the spoken "ee" to sound like "ay" ; indicates an underlying
consolidation (E A changes)
Abnormal respiratory sounds:
Crackles/Rales: Fine, med, course (course: loud bubbly noise heard during inspiration;
not cleared by cough)
Ronchi: (sonorous wheezes) Loud, low, course sounds; prolonged and continuous
Wheeze: (sibilant) musical noise; continuous, high pitched, whistling
Friction rub: dry rubbing or grating sounds over pericardium (pericarditis) or over lungs
(pleurisy)
HEART AND BLOOD VESSELS
1.
2.
3.
4.

Perform an examination of the cardiovascular system


Define terms relating to the cardiovascular exam.
Describe the clinical anatomy of the cardiovascular system.
List the equipment required for examination of the cardiovascular system.
Watch, pen, sphygmomanometer, stethescope
5. Describe the equipment for examination of the cardiovascular system.
6. List the methods used in the examination of the cardiovascular system.
7. List factors affecting blood pressure.
a. Left ventricular stroke volume
b. Distensibility of aorta and large arteries
c. Peripheral vascular resistance
d. Volume of blood
8. List the phases of blood pressure.
a. Systole contraction of left ventricle
b. Diastole left vent relaxation; filling time
9. List the normal ranges for systolic and diastolic pressures.
10. List the types of hypertension.
11. Describe the types of hypertension.
Category
Systolic Diastolic
Hypertension
Stage 3 (severe)
>180
>110
Stage 2 (moderate) 160-179 100-109

Physical Exam Test #2


Study Guide
Stage 1 (mild)
140-159 90-99
High Normal
130-139 85-89
Normal
<130
<85
Optimal
<120
<80
12. State the normal pediatric and adult pulse rates.
13. Describe the auscultatory gap and pulse pressures.
Auscultatory gap silent interval that may present between systolic and diastolic
pressures
Pulse pressure = Systolic Diastolic BP; normal is 30-40 mmHg
14. List the pulse points examined in the cardiovascular exam.
15. List common causes of tachycardia and bradycardia.
16. Describe the common causes of tachycardia and bradycardia
17. Describe the following signs and list associated conditions:
Pulsus Alternans pulse alternates in amplitude from beat to beat with regular
rhythm; indicates left vent failure
Pulsus Paradoxus decrease in pulse amplitude on inspiration; indicates
pericardial tamponade, constrictive pericarditis, or obstructive lung disease
Neck Vein Distention right sided heart failure, constrictive pericarditis,
tricuspid stenosis, or SVC obstruction
Bruits mumurlike sound of vascular rather than cardiac origin
18. Describe the procedure used in testing for JVD and Hepatojugular reflux.
a. JVD
i. Position patient w/ head elevated 30 degrees
ii. Turn head away from side inspecting
iii. Use tangential lighting
iv. Locate and ID pulses of internal jugular vein
v. Measure from top of oscillating column to vertical ruler at sternal
angle and add 5; 5-7cm normal
b. Hepatojugular reflux patient supine, knees flexed; table at 45o angle;
with tangential lighting, identify the highest point of jugular pulsation
while pressing for 30-60 over the RUQ; observe any rise in jugular venous
pulsation; abnormal if rise is > 1cm.
19. List the characteristics of varicose veins. Dilated, tortuous; walls may feel thickened
on palpation
20. Describe the characteristics of varicose veins.
21. Describe the Brodie Trendelenberg Test.
Retrograde Filling Test patient supine; elevate one leg to 90 degrees; occlude great
saphenous vein by manual compression; have patient stand and watch for refill while
still occluding vessel; should fill from below = 35 seconds
22. Describe the characteristics of thrombophlebitis.
Redness, thickening, tenderness along superficial veins; unilateral edema is DVT
23. List the step of the inspection of the peripheral vascular system to include:
nail perfusion, hair distribution, grading of edema, and skin temperature.

Physical Exam Test #2


Study Guide
24. List factors in the intensity of the heart sounds.
a. Timing diastolic or systolic
b. Shape Crescendo, Decrescendo, crescendo-decrescendo, pansystolic
c. Location
d. Radiation or transmission
e. Intensity - graded
25. Describe the grades of heart murmurs.
Grade Description
1
Faint; may not be heard in all positions
2
Quiet; heard immediately after placing stethoscope on chest
3
Moderately loud
4
Loud
5
Very loud; heard w/ stethoscope partially off chest
6
Heard w/ stethoscope entirely off chest (can hear when you walk in the door)
26. List the characteristics of the heart sounds.
27. Describe the charateristics of the heart sounds.

28. List conditions associated with the following heart sounds:


Third heard frequently in children and adults <40, pregnancy; low in pitch
(bell)
Fourth dull, low in pitch; increased resistance to ventricular filling; pulmonary
hypertension, pulmonic stenosis
29. Describe the characteristics of a pericardial friction rub.
3 short sounds associated w/ cardiac movement
a. Atrial systole
b. Ventricular systole
c. Ventricular diastole
Best heard in Herbs point; sounds scratchy (diaphragm)
30. List the conditions in which the point of maximal impulse may be displaced.
5

Physical Exam Test #2


Study Guide
Downward and left displacement may indicate cardiac disease or LVH
Upward and right displacement may indicate pregnancy or high left diaphragm.
31. List the causes of Hypotension.
32. List the abnormalities associated with Hypertension and describe them.
33. Perform on examination of the Heart and blood vessels.
Additional Information:
Bell Low pitch, S3, S4, bruits
Diaphragm High pitch, S1, S2, friction rub
Thrills - Graded 1-6; grade 4 is palpable; grade 6 is visible
Systole ejection clicks (semilunar valves)
Diastole opening snaps (mitral valve, S3, S4)
EXAMINATION OF THE ABDOMEN
1.
2.
3.
4.
5.

Perform an examination of the abdomen.


Define terms relating to the abdominal exam.
Describe the clinical anatomy of the abdomen.
List the methods used in the abdominal exam and describe them.
List the types and describe the characteristics of bowel sounds.
a. Bowel sounds increased or decreased; high pitched tinkling indicates
intestinal fluid and air under tension in dilated bowel; rushes of highpitched sounds w/ abdominal cramp indicate obstruction
i. Hypoactive - Slow, sluggish, scant; may be caused by late
obstruction, disease, peritonitis, paralyticileus
ii. Hyperactive - Rushes, borborygmi, gurgles; associated with hunger
or disease
iii. Absent sounds
b. Bruits hepatic suggests carcinoma of liver; vascular indicate partial
obstruction
c. Venous Hum soft humming indicates increased collateral circulation
between portal and systemic venous systems; hepatic cirrhosis
d. Friction Rubs grating w/ respiration; inflammation of peritoneal surface
of organ
6. List the types of pain elicited on an examination of the abdomen and describe them.
a. Abdominal wall tenderness persists when patient raises head and
shoulders
b. Visceral tenderness dull discomfort; no muscular rigidity or rebound
tenderness; aorta, liver, cecum, sigmoid colon
c. Tenderness from disease in chest / pelvis epigastric pain w/ chest signs,
acute pleurisy; bilateral above inguinal ligament, rebound tenderness,
acute salpingitis
d. Tenderness of peritoneal inflammation

Physical Exam Test #2


Study Guide
i. Acute cholecystitis RUQ; Murphys sign
ii. Acute pancreatitis epigastric tenderness, rebound tenderness, soft
abdominal wall
iii. Acute diverticulitis sigmoid colon; resembles left-sided
appendicitis
7. State the purpose of light and deep palpation.
a. Light palpation IDs abdominal tenderness, muscular resistance,
superficial organs and masses; reassure and relax patient
b. Deep palpation delineate abdominal masses
8. Describe the techniques for palpation of the liver and spleen.
a. Liver hand behind 11/12 ribs on right side and push up; other hand press
up and in; have patient inspire; may use hooking technique in obese
b. Spleen reach over and behind patient; press up while pressing in below
left costal margin; have patient take a breath
9. List the types of abdominal hernias and describe them.
a. Umbilical hernia protrusion through defective umbilical ring; more
common in infants
b. Incisional hernia protrusion through operative scar; smaller has worse
prognosis
c. Epigastric Hernia small midline protrusion through defect in linea alba,
between xiphoid and umbilicus
10. State the purpose and list the steps for the following tests:
Psoas irritation of psoas from appendicitis
Obturator muscle internal rotation stretches internal obturator muscle; right
hypogastric pain suggest inflammation of muscle from appendicitis
Rebound suggests peritoneal inflammation, as in appendicitis
Fluid wave ascites; tap on one flank and feel on other while patients hand is
down midline; hand prevents wave transmission through fat
Shifting dullness ascites; fluid shifts to dependent side
CVA tenderness pain indicates kidney infection or musculoskeletal cause
Perform an examination of the abdomen.
Additional Information:
Obstructed or distended gall bladder may present as palpable mass below liver
Kidney location - Extends from vertebral level T12 to L3; the right is lower than the left
due to liver compression
Organ Locations:
RUQ:
liver, gall bladder, pylorus, duodenum, head of pancreas, right adrenal gland, superior
aspect of right kidney, hepatic flexure of ascending colon, portion of ascending &
transverse colon.
LUQ:
left lobe of liver, spleen, stomach, body of pancreas, left adrenal gland, upper aspect of
left kidney, splenic flexure of colon, portions of transverse and descending colon.

Physical Exam Test #2


Study Guide

RLQ:
lower pole of right kidney, cecum, appendix, portion of ascending colon, right ovary and
tube, uterus (if enlarged), right ureter, bladder (if distended)
LLQ:
lower pole of left kidney, sigmoid colon, portion of descending colon, left ureter, left
ovary and tube.