Physical assessment:
Subjective
data
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Cough
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Shortness of breath
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Chest pain with breathing
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History of respiratory infections
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Smoking history
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Environmental exposure
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Patient-centered care
The normal range of findings/abnormal findings
Inspect the posterior chest
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Thoracic cage (normal)
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(abnormal)
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Note the shape and configuration of the chest
wall. The spinous processes should appear in a straight line. The thorax is
symmetric, in an elliptical shape, with downward sloping ribs, about 45
degrees relative to the spine. The scapulae are placed symmetrically in each hemithorax.
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Skeletal deformities may limit thoracic cage excursion: scoliosis,
kyphosis.
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(normal)
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(abnormal)
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The anteroposterior (ap) diameter should be less than the transverse
diameter. The ratio of ap to transverse diameter is about 0.70 to 0.75 in
adults and it increases with age.
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Ap = transverse diameter, or “barrel chest.” Ribs are horizontal, a chest appears as if held in continuous inspiration. This occurs in COPD from hyperinflation of the lungs.
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(normal)
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(abnormal)
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The neck and trapezius muscles should be developed normally for age
and occupation.
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Neck muscles are hypertrophied in COPD from aiding in forced
respirations across the obstructed airways.
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Note the position the person takes to breathe. This includes a
relaxed posture and the ability to support one's own weight with arms
comfortably at the sides or in the lap.
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People with COPD often sit in a tripod position, leaning forward with
arms braced against their knees, chair, or bed. This gives them leverage so
the abdominal, intercostal, and neck muscles all can aid in expiration.
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Assess skin color and condition. Color should be consistent with
person's genetic background, with allowance for sun-exposed areas on the chest and the back. No cyanosis or pallor should be present. Note any lesions. Inquire about any change in a nevus on the back (e.g., where the person may have difficulty monitoring.
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Cyanosis occurs with tissue hypoxia.
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Palpate the posterior chest
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Symmetric expansion (normal)
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(abnormal)
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Confirm symmetric chest expansion by placing your warmed hands
sideways on the posterolateral chest wall with thumbs pointing together at the level of t9 or t10. Slide your hands medially to pinch up a small fold of the skin between your thumbs.
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Unequal chest expansion occurs with marked atelectasis, lobar
pneumonia, pleural effusion, thoracic trauma such as fractured ribs, or
pneumothorax.
Pain accompanies deep breathing when the pleurae are inflamed.
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Tactile fremitus (normal)
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(abnormal)
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Assess tactile (or vocal) fremitus. Fremitus is a palpable vibration.
Sounds generated from the larynx are transmitted through patent bronchi and
the lung parenchyma to the chest wall, where you feel them as vibrations.
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Use either the palmar base (the ball) of the fingers or the ulnar
edge of one hand and touch the person's chest while he or she repeats the
words “ninety-nine” or “blue moon.” These are resonant phrases that generate strong vibrations. Start over the lung apices and palpate from one side to another.
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Symmetry is most important; the vibrations should feel the same in
the corresponding area on each side. Avoid palpating over the scapulae
because bone damps out the sound transmission.
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Asymmetric findings suggest dysfunction that you can assess further
with the stethoscope.
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Note any areas of abnormal fremitus. Sound is conducted better
through a uniformly dense structure than through a porous one, which changes
in shape and solidity (as does the lung tissue during normal respiration).
Thus, conditions that increase the density of lung tissue make a better conducting
medium for sound vibrations and increased tactile fremitus.
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Decreased fremitus occurs with obstructed bronchus, pleural effusion
or thickening, pneumothorax, or emphysema. Any barrier that comes between the
sound and your palpating hand decrease fremitus.
Increased
fremitus occurs with compression or consolidation of lung tissue (e.g., lobar pneumonia). This is present only when the bronchus is patent, and the consolidation extends to the lung surface. Note that only gross changes increase fremitus. Small areas of early pneumonia do not significantly affect
it.
Rhonchi fremitus is palpable with thick bronchial secretions.
Pleural friction fremitus is palpable with inflammation of the.
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(normal)
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(abnormal)
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Using the fingers, gently palpate the entire chest wall. This enables
you to note any areas of tenderness, to note skin temperature and moisture,
to detect any superficial lumps or masses, and to explore any skin lesions
noted on inspection.
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Crepitus is a coarse, crackling sensation palpable over the skin
surface. It occurs in subcutaneous emphysema when air escapes from the lung
and enters the subcutaneous tissue, as after open thoracic injury or surgery.
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Percuss the posterior chest (normal)
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(abnormal)
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Resonance is the low-pitched, clear, hollow sound that predominates
in healthy lung tissue in the adult. However, resonance is a relative term and has no constant standard. The resonant note may be duller in the athlete
with a heavily muscular chest wall and in the heavily obese adult in whom
subcutaneous fat produces scattered dullness
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Asymmetry is important: one side with prominent dullness or marked hyper resonance indicates an underlying disease. Hyperresonance is a lower-pitched, booming sound found when too much air is present such as in
emphysema or pneumothorax.
A dull note (soft, muffled thud) signals
abnormal density in the
lungs, as with pneumonia, pleural effusion, atelectasis, or tumor.
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Auscultate the posterior chest (normal)
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(abnormal)
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The passage of air through the tracheobronchial tree creates a characteristic set of sounds that are audible through the chest wall
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Breath sounds (normal)
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(abnormal)
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Evaluate the presence and quality of normal breath sounds. The person
is sitting, leaning forward slightly, with arms resting comfortably across the lap. Instruct the person to breathe through the mouth, a little bit deeper than usual, but to stop if he or she begins to feel dizzy. Be careful to monitor the breathing throughout the examination and offer times for the person to rest and breathe normally. The person is usually willing to comply
with your instructions to please you and be a “good patient.” Watch that he or she does not hyperventilate to the point of fainting.
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Clean the flat diaphragm earpiece of the stethoscope and hold it firmly
on the person's chest wall. Listen to at least one full respiration in each location. Side-to-side comparison is most important.
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Do not confuse background noise with lung sounds. Become familiar
with these extraneous noises that may be confused with lung pathology if not
recognized:
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1. Examiner's breathing on the stethoscope tubing
2. Stethoscope tubing bumping together
3. Patient shivering
4. Patient's hairy chest: movement of hairs under stethoscope sounds
like crackles (rales)—minimize this by pressing harder or by wetting the hair
with a damp cloth
5. The rustling of paper gown or paper drapes
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Crackles are abnormal lung sounds
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While standing behind the person, listen to the following
lung areas: posterior from the apices at c7 to the bases (around t10) and
laterally from the axilla down to the 7th or 8th rib.
Continue to visualize approximate locations of the lobes of
each lung so you correlate your findings to anatomic areas. As you listen,
think (1) what am I hearing over this spot? And (2) what should i expect to be
hearing?
You should expect to hear three types of a normal breath
sounds in the adult and older child:
Bronchial (sometimes called tracheal or tubular)
Bronchovesicular
Adventitious sounds (normal)
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(abnormal)
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Note the presence of any adventitious sounds. These are added sounds
that are not normally heard in the lungs. If present, they are heard as being superimposed on the breath sounds. They are caused by moving air colliding with secretions in the tracheobronchial passageways or by the popping open of previously deflated airways. Sources differ as to the classification and
nomenclature of these sounds but crackles (or rales) and wheeze (or rhonchi)
are terms commonly used by most examiners. If you hear adventitious sounds,
describe them as inspiratory versus expiratory, loudness, pitch, and location
on the chest wall.
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Crackles are discontinuous popping sounds heard over inspiration;
wheezes are continuous musical sounds heard mainly over expiration. Study for
a complete description of these and other abnormal adventitious breath
sounds.
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Vesicular:
Characteristics of normal breath sounds
Inspect the anterior chest (normal)
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(abnormal)
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Note the shape and configuration of the chest wall. The ribs are
sloping downward with symmetric interspaces. The costal angle is within 90
degrees. The development of abdominal muscles is as expected for the person's age, weight, and athletic condition.
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Barrel chest has horizontal ribs and costal angle >90 degrees.
Hypertrophy of abdominal muscles occurs in chronic emphysema.
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Note the person's facial expression. The facial expression should be
relaxed and benign, indicating an unconscious effort of breathing.
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Tense, strained, tired facies and purse-lipped breathing (the lips in
a whistling position) accompany COPD. By exhaling slowly and against a narrow
opening, the pressure in the bronchial tree remains positive, and fewer
airways collapse.
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Assess the level of consciousness. The level of consciousness should
be alert and cooperative.
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Cerebral hypoxia may be reflected by excessive drowsiness or anxiety,
restlessness, and irritability.
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Note skin color and condition. The lips and nail beds are free of
cyanosis or unusual pallor. The nails are of normal configuration. Explore
any skin lesions.
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Clubbing of distal phalanx occurs with COPD because of the growth of
vascular connective tissue.
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Cutaneous
angiomas (spider nevi) associated with liver disease or portal hypertension
may be evident on the chest.
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Assess the quality of respirations. Normal relaxed breathing is
automatic and effortless, regular and even, and produces no noise. The chest expands symmetrically with each inspiration. Note any localized lag on
inspiration.
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Noisy breathing occurs with severe asthma or chronic bronchitis.
Unequal chest expansion occurs when part of the lung is obstructed
(pneumonia) or collapsed or when guarding to avoid postoperative or pleurisy
pain.
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No retraction or bulging of the interspaces should occur on
inspiration.
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Retraction suggests obstruction of the respiratory tract or that the increased inspiratory effort is needed, as with atelectasis. Bulging
indicates trapped air as in the forced expiration associated with emphysema
or asthma.
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Normally accessory muscles are not used to augment respiratory
effort. However, with very heavy exercise the accessory neck muscles
(scalene, sternomastoid, trapezius) are used momentarily to enhance
inspiration.
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Accessory muscles are used in acute airway obstruction and massive
atelectasis.
Rectus abdominis and internal intercostal muscles are used to force
expiration in COPD.
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The respiratory rate is within normal limits for the person's age and
the pattern of breathing is regular. Occasional sighs normally punctuate
breathing.
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Tachypnea and hyperventilation, bradypnea and hypoventilation,
periodic breathing.
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Palpate the anterior chest (normal)
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(abnormal)
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Palpate symmetric chest expansion. Place your hands on the
anterolateral wall with the thumbs along the costal margins and pointing
toward the xiphoid process.
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Abnormally wide costal angle with little inspiratory variation occurs
with emphysema.
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Ask the person to take a deep breath. Watch your thumbs move apart
symmetrically and note smooth chest expansion with your fingers. Any
limitation in the thoracic expansion is easier to detect on the anterior chest
because a greater range of motion exists with breathing here.
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A lag in expansion occurs with atelectasis, pneumonia, and
postoperative guarding. A palpable grating sensation with breathing indicates
pleural friction fremitus.
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Assess tactile (vocal) fremitus. Begin palpating over the lung apices
in the supraclavicular areas. Compare vibrations from one side to the other
as the person repeats “ninety-nine.” Avoid palpating over female breast tissue because breast tissue normally damps the sound. Assess tactile fremitus.
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Palpate the anterior chest wall to note any tenderness (normally none
is present) and detect any superficial lumps or masses (again, normally none are present). Note skin mobility and turgor and skin temperature and
moisture.
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If any lumps are found in the breast tissue, refer the patient to a
specialist.
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Percuss the anterior chest (normal)
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(abnormal)
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Begin percussing the apices in the supraclavicular areas. Then,
percussing the interspaces and comparing one side with the other, move down the anterior chest.
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Interspaces are easier to palpate on the anterior chest than on the
back. Do not percuss directly over female breast tissue because this would produce a dull note. Shift the breast tissue over slightly, using the edge of your stationary hand. In females with large breasts, percussion may yield
little useful data.
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Note the borders of cardiac dullness normally found on the anterior
chest, and do not confuse these with suspected lung pathology. In the right hemithorax, the upper border of liver dullness is in the 5th intercostal space in the right midclavicular line. On the left, tympany is evident over the gastric space. 18-25 expected percussion notes.
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Lungs are hyperinflated with chronic emphysema, which results in hyper resonance where you would expect cardiac dullness.
Dullness behind the right breast occurs with right middle lobe
pneumonia.
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Auscultate the anterior chest (normal)
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Breath sounds
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Auscultate the lung fields over the
anterior chest from the apices in
the supraclavicular areas down to the 6th rib. Progress from side to side as you move downward and listen to one full respiration in each location. Use the sequence indicated for percussion. Do not place your stethoscope directly over the female breast. Displace the breast and listen directly over the
chest wall.
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Evaluate normal breath sounds, noting any abnormal breath sounds and
adventitious sounds. If the situation warrants assess the voice sounds on
the anterior chest.
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Thorax, lungs, and breasts:
Behavior performance:
Chest
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Gather subjective data
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Inspect: general appearance:
§
Respiratory pattern
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Skin color/cyanosis or pallor
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Facial expression
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Loc and orientation (self, time, place,
person).
§
Position
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Inspect
posterior chest and lateral chest:
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Shape (ap vs. Transverse diameter)
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Skeletal deformities
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Palpate posterior chest and lateral chest:
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Confirm symmetrical expansion at 10th
thoracic space
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Masses, tenderness, crepitus
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Percuss posterior chest and lateral chest:
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Identify percussion notes (resonance)
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Symmetry over lung fields
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Auscultate posterior chest
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Assess normal breath sound
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Note any abnormal(adventurous) breath sounds
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Auscultate lateral chest
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Assess normal breath sounds
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Note any abnormal(adventurous) breath sounds
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Inspect anterior chest (note any deformities)
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Percuss anterior chest (displace breast).
Identify notes and symmetry.
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Auscultate anterior chest
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Assess normal breath sounds
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Note any abnormal(adventurous) breath sounds.
· The normal range of findings/abnormal find.
Assessment part
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Subjective data-health history questions:
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Leg pain or cramps
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Skin changes on arm or legs
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Swelling
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Lymph node enlargement
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Medications.
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Objective data: the physical exam:
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Utilizes inspection and palpation
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Generally examined region by region during the
examination of the other body systems
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Always ask patients if they are aware of any
“lumps”.
Lymph nodes accessible to examination:
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Head and neck:
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Preauricular
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Postauricular
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Occipital
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Tonsillar
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Submandibular
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Submental
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Superficial anterior cervical
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Deep cervical
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Posterior cervical
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Supraclavicular
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Infraclavicular
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The arms:
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Axillary:
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Anterior axillary (pectoral)
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Lateral (brachial)
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Mid axillary (central)
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Posterior (subscapular)
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The legs:
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Superficial superior inguinal
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Superficial inferior inguinal
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Inspect:
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Any visible nodes for:
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Edema
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Erythema
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Red streaks
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Palpate
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The superficial nodes
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Compare side to side for:
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Size
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Consistency
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Mobility
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Discrete borders or matted
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Tenderness
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Warmth
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If an enlarged lymph node is found, examine:
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P primary
site
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A all
associated nodes
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L liver
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S spleen
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