Fundamentals of Physical Examination

Chapter 5

Physical Examination

• Inspection• Palpation• Percussion• Auscultation

Physical Exam• Determine the correct diagnosis• Proficiency is attained through practice• Typical format for recording the exam includes:– Initial impression– Vital signs– HEENT– Neck– Thorax– Abdomen– Extremities

Head

• Facial expression• Nasal flaring• Cyanosis• Pursed lip breathing

Eyes

• Pupillary reflexes – PERRLA• Mydriasis• Miosis• Ptosis• Diplopia• Nystagmus

Neck

• JVP• Accessory muscle use• Tracheal position• Lymph nodes• Carotid pulse

Lung Topography

Anterior Chest Posterior Chest

Lung Topography

Lateral Chest

Thoracic Cage Landmarks

Anterior Chest Posterior Chest

Lung Fissures

Thoracic Inspection• Thoracic configuration

– Pectus carinatum– Pectus excavatum– Kyphosis– Scoliosis– Kyphoscoliosis– Flail chest

• Central cyanosis

• Breathing patterns– Apnea– Biots– Cheyne stokes– Kussmauls– Apneustic– Paradoxical– Asthmatic

• Breathing Effort– Retractions/bulging– Abdominal paradox– Respiratory alterans– Hoover’s sign

Thoracic Palpation

• Vocal fremitus• Tactile fremitus• Thoracic expansion• Skin and subcutaneous tissues

Thoracic Percussion

• Indirect percussion • Lung fields– Normal resonance– Increased resonance– Decreased resonance

• Diaphragmatic Excursion

Lung Auscultation• Tracheal breath sound• Bronchovesicular• Vesicular• Bronchial• Adventitious– Wheeze– Crackles– Rhonchi– Stridor– Pleural friction rub

Figure 05-19 Location on chest wall where normal bronchovesicular and vesicular breath sounds are heard. A, Anterior bronchovesicular. B, Posterior bronchovesicular. C, Anterior vesicular. D,

Posterior vesicular. (From Wilkins RL, Hodgkin JE, Lopez B: Fundamentals of lung and heart sounds, ed 3, St Louis, 2004, Mosby.)

Wheezing vs Crackles

Voice Sounds

• Brochophony• Egophony• Whispering pectoriloquy

Precordium

• Heart topography• Point of maximal impulse – PMI• Heart sounds

Neurologic Exam

• Suspected brain or spinal cord injury• Assessment of LOC• Brainstem

Abdomen

• Hepatomegaly• Ascites

Extremities

• Clubbing• Cyanosis• Pedal edema• Capillary refill• Peripheral skin temperature