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a. general examination :
1. inspect movement with respiration
females normally move their thorax
males normally move their abdomen
**using accessory muscles in respiration >> severe COPD and acute severe
asthma
**pursed lips >> severe COPD , during expiration
**abdomen and thorax move paradoxically during inspiration ( abdomen moves
**in and thorax moves out ) >> severe respiratory failure
2. stridor : ask the ptn to cough then take deep breath in and out with opened
mouth and hear if there is stridor
3. cyanosis : check at lips and under tongue
cyanosis occur if O2 saturation falls below 90 %
if ptn is polycythemic cyanosis appear before if the ptn was anemic
4. blood pressure and pulse :** if diastolic less than 60 mmHg increase mortality
rate in community acquired pneumonia
5. skin appearance :
**erythema nodosum over the skin >> acute sarcoidosis or TB
**metastatic skin nodules of lung cancer
b. hands :
1. clubbing :** seen in lung cancer , bronchoctasis , interstitial lung disease and
empyema
2. discoloration of finger and nails :
**brownish stain : tan from smoking
**yellow nail syndrome : lymphoedema and exudative pleural effusion
3. tremor :
**fine finger tremor : excessive use of beta agonist ( bronchodilator drugs )
**flapping tremor : CO2 retention in severe ventilator failure
to test for it u can ask the ptn to grip ur index and middle finger for 30-60
seconds if he couldn`t then he have flapping tremor
c. neck :
1. jugular vein pressure :
**raised in 1. Right sided heart failure ( cor pulmonale )
2. Chronic hypoxia in COPD
3. Tension pnuemothorax
4. Severe acute asthma
5. Massive pulmonary embolism
6. Superior vena cava obstruction SVCO ( JVP is raised and non pulsatile )
Group A5/2010
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Beats
Palpation
Occlusion
JVP
Twice per cardiac cycle
Non palpable
Occluded by pressing against
neck
Vary with HUT
Decrease with deep inspiration
carotid
Once per cardiac cycle
Palpable
Not occluded
Not variable
Not variable
d. thorax :
examine the back of the thorax then the front
1. chest shape :
**1. Barrel shaped :in severe COPD
**2. Kyphoscoliosis : produce CO2 retention and cor pulmonale in early age
**3. Pectus carinatum ( pigon chest ) with harison sulcus : seen in poorly
controlled childhood asthma or maybe seen in rickets or ostiomalacia
**4. Pectus excavatum ( funnel chest ) : usually asymptomatic
2. skin :
**metastatic tumor nodules
**neurofibroma or lipoma
**dilated veins in SVCO
3. palpation :
1. Palpate the trachea , slight displacement to right is normal
2. Mesure distance between suprasternal notch and cricoids cartilage , should be
3-4 fingers ,** if less >> lung hyperinflation
3. Palpate apex beat , if displaced
Group A5/2010
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Group A5/2010
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Group A5/2010
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