Chest/Lungs/Percussion/Auscultation/Heart

Chest & Lungs: 1-2. RR & Rhythm 3. Chest is symmetrical, no chest wall deformities, clavicles prominent, sternal configuration is flat an no rib abnormalities 4. A/P transverse diameter is 1:2 5. No spinal deformities-now palpate...stand behind pt 6. take 1st 3 fingers press on spine and paravertebral muscles, go to end of spine-ask about tenderness 7. Respiratory expansion/excursion: thumbs at 10th rib, slide thumbs medially to raise loose skin fold ask pt to inhale deeply-feel for range and symmetry-say symmetric posterior chest excursion

Percuss Posterior Chest: 1. Percuss @ apices then side-to-side for symmetry on inter-space-never on ribs-say resonance percussed over all lung fields. Tympani=cavity w/ air =abd Resonance = lungs Dullness=over mass Flatness=muscle mass Diaphragmatic Excursion: percuss @ scapula, move down, ask pt to take deep breath in-diaphram moves down-mark w/ pen-exhale & percuss up-mark area w/ pen-measure= 3-6 cm -say thorax expanded 5 cm 3. Blunt percussion: palm of hand over CVA-tap w/ ulnar fist-say CVA free of tenderness or pain

Auscultation: 1. breath sounds: ask pt to open mouth & breath in & out. Ausculatate apices the side-to-side, then lung, ask pt to lift arm to mid rib area towards axilla Say vesicular breath sounds noted in all lung fields & no advetisious breath sounds 2. Now listen for voice sounds, say 99 listen over lung fields voice transmission is soft, muffled and indistinct. Say-no consolidation, no bronchophony (distinct voice sounds), no egophony (eeee sounds like aaa) or whiipered pec-to-ril-o-quy (again voice is clear) is noted

Heart: 1. Inspection: (sitting) apical pulsation: visible at P-M-I 5th ICS-LMCL No lateral displacement, no lifts (heaves) or retractions detectable on chest wall 2. Lie down-check JVD @ 10 degrees-if + HOB 30-45 degrees up and see if disappeared 3. Palpation: check all valve locations w/ palm, then apical pulse, say no thrills noted 4. Location of apical pulse-say impulse is gentle & brief-no thrill @ apex or base palpable 6. While palpating apex, use other hand & pallpate carotid artery-say carotid pulse & S1 are synchronous

Auscultation: 7. Place stethoscope (bell) over carotid artery; ask pt to hold breath. Bruits are heard at the lateral end of clavicle & posterior margin of sternocleidomastoid muscle-say no bruits noted 8. Compare S1 (loudest @ apex-mitral) exhale & hold w/ S2 (loudest @ pulmonic base) inhale & hold say- S1 is longer and louder than S2. 9. HR is __, 10. Rhythym: is regular/irregular 11. B/P 12 Aortic 2nd ICS-RMCL 13. Pulmonic 2nd ICS-LMCL 14. Erb's point 3rd ICS-LSB 15. Tricuspid: 4th ICS-LSB 16. Mitral (cardia apax) 5th ICS-LMCL