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Basic Physical Examination

Physical examination helps the doctor to determine the general status of patient’s health. A complete physical examination usually starts from the head and proceeds all the way to toes. However, the procedure may vary as per the case presented and the preferences of the examiner.

Generally, there are 4 parts of physical examination:

●     Inspection : Where the physician looks for signs

●     Palpation : Feeling the signs

●     Percussion : Tapping for signs, used when doing a lung, heart or gut examination.

●     Auscultation : Listening for sounds within the body using a stethoscope, or in olden times, purely listening with direct ear.

Systemic examination reviews the major systems of the body like the Central nervous system, Respiratory system, Cardiovascular system and Gastrointestinal system.

Examination of the Respiratory system

Clinical examination of the respiratory system is carried out to assess the functional status of the respiratory tract and lungs.
  1. General examination: Before doing the examination of the respiratory system, a general examination relevant to the respiratory system should be carried out.
    Which includes -Appearance, Pallor, Cyanosis, Clubbing (excessive curvature of the nail), Venous pulses, Lymph node enlargement
  2. Personal History: Stress on the following points
    Occupation: e.g. – Silicosis may be complicated by pulmonary T.B.,  Asbestosis may be complicated by mesothelioma
    Ask about the following:
    a. Duration of exposure: several years needed for pneumoconiosis.
    b. Adherence to safety measures as wearing special masks.
    c. Addictions such as smoking cigarettes, shisha and goza.
  3. The six cardinal symptoms of chest diseases are:
    a. Cough
    b. Expectoration (sputum)
    c. Hemoptysis
    d.Chest pain
    e. Dyspnea
    f. Wheezes
  4. Other symptoms of importance in chest diseases :
    1- Symptoms of mediastinal syndrome as dysphagia and hoarseness of voice.
    2- Symptoms of toxemia as night fever, night sweats, loss of appetite and weight as in T.B.
    3- Symptoms of RVF as LLs edema and pain in the RUQ of the abdomen ( due to congested tender liver).
    4- Fever as in upper and lower respiratory tract infections.
    Finally any other symptoms related to other systems. History of the present illness2
  5. Associated conditions – Attack or disease similar to the present one:
    e.g. – Asthma. – Recurrent pneumonia
    – Allergic disorders: eczema, urticaria, angioedema and hay fever.
    – Acute abdominal conditions.
    – Admission in any hospital before and why?
    – Bilharziasis: bilharzial cor pulmonale.
  6. Chest injuries and operations.
    Other Surgical Procedures.
    Coma , convulsion – may predispose to aspiration lung abscess
    Cardiac diseases and history of rheumatic fever.
  7. Past History-
    Diabetes mellitus
    Hypertension- Cough may result from ACE inhibitors
    T.B and history of admission to a chest hospital for treatment of T.B. medicines, duration of the treatment and the adherence to it.
    Previous radiological examination: comparison with the current radiograph
  8. Family and Social History- Similar condition in the family.
    – History of T.B.
    – History of allergy as eczema and hay fever.
    – History of DM
  9. Analysis of Chest Symptoms – Ask about the following:
    – The frequency
    – The severity
    – Dry or productive
    – Time of occurrence
    – Relation to posture
    – Character of cough (better observed by the physician)
  10. Sputum
    – Amount
    – Color
    – Character (seous, mucoid,purulent and mucopurulent)
    – Odor
    – Relation to posture
    – What increases or decreases it
  11. Hemoptysis :The most important causes of hemoptysis are
    •Mitral stenosis
    •Pulm tuberculosis
    •Pulm infarction
    •Brochiectasis
    •Bronchogenic carcinoma
    •Bronchial adenoma
    •Bleeding tendency
  12. Differentiate between hemoptysis and hematemesis
    Ask about :
    •Type and Degree
    •Frequency and Duration . Ask about the preceding events e.g. DVT or chest infection
    •Frank hemoptysis
    •Blood-stained sputum
    •Blood streaked sputum
    •Rusty sputum
  13. Chest pain:
    – The onset.
    – Site.
    – Character.
    – Radiation.
    – What increases the pain
    – what relieves or decreases it.
  14. Wheeze – What dose the patient mean by wheezing?
    Differentiate between wheeze and stridor.
    Wheezing may be intermittent as in asthma or persistent as in chronic bronchitis.
    Wheezing may be diffuse as in asthma and chronic bronchitis or localized as in bronchogenic carcinoma.

Inspection

1) Ask the patient to lie supine.
2) Ask the patient to lower his gown to waist level.
3) Stand at the feet of patient.
4) Inspect the shape of the chest (ratio of antero-posterior and transverse diameters).
5) Inspect the symmetry of the patient’s chest on both sides with comparison.
6) Chest wall – Pectus carinatum,  Pectus excavatum

  • Shape of the chest – The normal chest is bilaterally symmetrical and elliptical in cross section the transverse diameter anteroposterior diameter Comman abnormalities of shape-
    kyphosis-forward bending of vertebral column
    scoliosis- lateral bending of vertebral column
    barrel shaped chest- increase in anteroposterior diameter flattening
  • Rate & Rhythm of respiration Rate of respiration in health (adult) 12-14 breaths/min
  • Measurement of chest expansion chest expansion can be measured with a tape measure around the chest just below the nipples in a healthy adult it is about 3-5 cm
  • Symmetry of chest expansion chest expansion of a healthy adult should be equal on both sides
  • Movements of the chest wall presence of intercostal recessions or the use of accessory muscles
  • Inspection of anterior chest wall:
  • Inspect patient’s chest normal breathing movement.
  • Inspect patient’s chest for accessory muscle use.
  • Inspect patient’s chest for retraction of lower intercostal spaces.
  • Stand again to the right of patient and look tangentially for apical and epigastric pulsation.
  • Inspect the chest wall and skin for swelling, scars, skin eruption or engorged veins.

Palpation

  1. Before making a systemic examination palpate any part of the chest where the patient complains of pain or where there is a swelling
  2. Position of the Apex beat and Trachea – In normal subjects the trachea is in the midline and can be palpated in the suprasternal notch the apex beat (the lowest and outermost point of definite cardiac pulsations) can be usually palpated in the 5th intercostal space within the midclavicular line Displacement of the apex beat and trachea indicates that the position of the mediastinum has been altered This may be due to diseases of the heart, lungs or pleura
  3. Expansion of the chest Symmetrical or asymmetrical chest expansion can be assessed by palpation
  4. Vocal fremitus Vocal fremitus is the vibration detected by palpation with the palm of the hand on the chest, when the patient is asked to repeat “ninety nine” or “anunavaya” In a normal healthy adult, the vibrations felt in the corresponding areas on the two sides of the chest are equal in intensity

Palpation of anterior chest wall –
1) Stand to the right of the patient.
2) Ask the patient to lie supine.
3) Palpate upper lung zone to confirm the movement by placing the palms in the infraclavicular fossa and the two thumbs in the midline at the level of suprasternal notch. Let the patient inspire deeply and let your thumbs follow chest movement.
4) Palpate middle lung zone by putting the palm in the middle part with tips of thumbs in the midline. Let the patient inspire deeply and let your thumbs follow chest movement.
5) Palpate lower lung zone by putting the palm in the lower part with tips of thumbs in the midline. Let the patient inspire deeply and let your thumbs to follow chest movement.
6) Palpate for palpable rhonchi, pleural rub or chest wall tenderness by putting the palm on various areas of chest wall.
7) Palpate for Tactile vocal fremitus
a) Place the palm of hand over various area of chest wall in the direction of bronchial tree away from midline with comparison.
b) Ask the patient to repeat the words “44” in arabic

Increased TVF Decreased TVF – Consolidation, Cavitation , Collapse with patent main bronchus , Thick chest wall , Pleural effusion , Pleural fibrosis , Pneumothorax , Emphysema ,Collapse

Tracheal examination:
a) Stand to the right of the patient.
b) Ask the patient to sit up with the head straight.
c) Inspect for tracheal position “Trill’s sign”.
d) Tracheal shift: Insert the index finger in horizontal position in the pouch between the medial end of sternomastoid and the lateral aspect of trachea with comparison.
e) Check the cricosternal distances. This is the distance between the cricoid cartilage and the suprasternal notch. If it is less than 3 finger breadths, this indicates hyperinflation of the lung.
f) Tracheal descent: place the tip of the index finger on the thyroid cartilage during inspiration to observe its descent.

Percussion

A resonant sound is produced during percussion
The sound and feel of resonance over a healthy lung has to be learned by practice

Percussion technique
a. Place left hand on chest wall, palm downwards with fingers separated
b. 2nd phalanx over area of intercostal space
c. Right middle finger strikes the 2nd phalanx producing hammer effect
d. Entire movement comes from wrist

  • Percussion of the chest anterior chest wall
    a. Stand to the right of the patient.
    b. Ask the patient to lie supine.
    c. Use light percussion.
    d. Krönig’s isthmus: Percuss both areas right and left from dullness to resonance (start from the neck) with comparison.
    e. Percuss both clavicles directly (over medial third)
    f. Percuss the infraclavicular regions.
    g. Percuss both parasternal lines right and left, from the second space to the sixth space with comparison.
    h. Spare bare area to be percussed late with special areas percussion.
    i. Percuss both midclavicular lines right and left, from the second space to the sixth space with comparison.
    j. Comment on dullness found.
  • Percussion of the lateral chest wall
    a. Stand to the right of the patient.
    b. Ask the patient to lie supine and raise his hands above his head.
    c. Use light percussion.
    d. Percuss both anterior axillary lines right and left, from the fourth space to the eighth space with comparison.
    e. Percuss both middle axillary lines right and left, from the fourth space to the eighth space with comparison.
    f. Percuss both posterior axillary lines right and left, from the fourth space to the eighth space with comparison.
    g. Comment on dullness found.
  • Upper border of the liver
    1- Stand to the right of the patient.
    2- Ask the patient to lie supine.
    3- Use heavy percussion.
    4- Start in the right midclavicular line from second space down to the first dullness.
    5- Decide the upper border of the liver.
  • Bare area of the heart
    1- Stand to the right of the patient.
    2- Ask the patient to lie supine.
    3- Place the left hand in the left 4th and the 5th spaces between midline and parasternal line.
    4- Percuss lightly with right hand.
    5-Comment.
  • Tidal percussion
    1- Stand to the right of the patient.
    2- Ask the patient to sit.
    3- After percussing the back using heavy percussion if any infrascapular dullness was found, fix the left hand over it and ask the patient to take a deep breath and hold it then percuss again.
    4- Comment on whether it changed to be resonant or not and explain.
  • Kronig’s isthmus
    1- Stand to the right of the patient.
    2- Ask the patient to sit and stand behind him.
    3- Use light percussion.
    4- Percuss both areas right and left from dullness to resonance with comparison.
    5- Comment on dullness found.   Auscultation
  • Normal Breath sounds – There are 2 types of breath sounds
    – vesicular breath sounds – The vesicular breathing is lower pitched and softer than bronchial breathing.
    – bronchial breath sounds
  • The breath sounds are symmetrical and louder in intensity in bases compared to apices in erect position and dependent lung areas in decubitus position.
  • Vesicular breath sounds – These originate in the larger airways and are produced by the passage of air in and out of normal lung tissue In good health, they can be heard all over the chest.
    – Expiration is shorter (I > E) and no pause between inspiration and expiration.
    – the inspiratory sound is intense and louder than the expiratory sound
    – it is a low pitched rustling sound
    – there is no gap between inspiration and expiration
    Vesicular breathing with prolonged expiration example: airway obstruction (asthma)
  • Bronchial breath sounds – These are produced by the passage of air in the trachea and larger bronchi In good health, they can be heard only over the trachea In disease, bronchial breathing may be heard over the area of lung that is affected (lung collapse,fibrosis or when there is a cavity)
    – The breath sounds over tracheobronchial tree are bronchial breathing. – only place where tracheobronchial trees are close to chest wall without surrounding lung tissue are – Trachea ,right sternoclavicular joints , posterior right interscapular space. These are the sites where bronchial breathing can be normally heard.
    – the expiration is long as or longer than inspiration – prolonged expiratory phase (E > I) indicates airway narrowing, as in: Vesicular breathing with prolonged expiration, Bronchial asthma, Chronic bronchitis
    – the pitch and sound of the expiration is loud or louder than the inspiratory sounds.
    – there is a gap between inspiration and expiration
    – bronchial breath sounds have a higher pitch, louder, inspiration and expiration are equal and pause between inspiration and expiration.
  •  Vocal resonance – The resonant sound that is heard with the stethoscope when the patient is asked to repeat “ninety nine” or “anunavaya”
    This depends on the loudness and the depth of the patients voice and the conductivity of the lungs.
  • Added sounds – These are abnormal sounds that arise in the pleura or lungs
    Rhonchi – wheezing sounds (asthma)
    Crepitations – bubbling or crackling noises
    Pleural rub – creaking or rubbing noises associated with pain

Technique of Auscultation
•Patient relaxes and breathes normally with mouth open, auscultate lungs, apices and middle and lower lung fields posteriorly, laterally and anteriorly. •Alternate and compare both sides at each site.
•Listen at least one complete respiratory cycle at each site.
•Listen to quiet respiration. If sounds are inaudible, then ask him take deep breaths.
•First describe the breath sounds and then the adventitious sounds.
•Note intensity of breath sounds and compare with opposite side.
•Assess length of inspiration and expiration.
•Listen for a pause between inspiration, expiration and the quality of pitch of sound
•compare intensity of breath sounds between upper and lower chest in upright position.
•Compare intensity of breath sounds from dependent to top lung in decubitus position.
•Note the presence or absence of adventitious sounds.

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24 year old male patient with diffused agonising abdominal pain…

आयर्वेद परीक्षा व चिकित्सा आधार