RS Physical Examination Hadeel Khadawardi, teaching assistant at Internal Medicine Department, Faculty of Medicine, Umm Al-Qura University

Introduction General Approach Vital Signs Position Coughing/ Sputum Strider/ Wheezing Vital Signs Position 45 sitting over the edge of bed or on chair

RS Exam Peripheral Exam Chest Exam Hand Inspection Wrist Palpation Face Neck ? Inspection Palpation Percussion Auscultation

Hand Nail Fingers Dorsum

Hand Nail Clubbing / HPO Peripheral Cyanosis What are the causes of clubbing? What is the chronic respiratory disease that dose not cause clubbing?

Hand Fingers Nicotine Stain

Hand Dorsum Muscle Wasting

Wrist Flapping tremor (Asterixis) What are the causes of flapping tremor? What is fine tremor?

Face Eyes Nose Mouth Sinuses

Face Eye Pallor Horner’s Syndrome Meiosis Partial ptosis Loss of sweating

Face Nose Deviated nasal septum Polyps Enlarged turbinate

Face Mouth Peripheral cyanosis Central cyanosis Signs of URTI Infected teeth

Face Sinuses

JVP Neck ?

Chest Exam Expose the chest properly to the waist including the axilla. Exam the anterior and posterior chest. Inspection, Palpation, Percussion, Auscultation Always compare the right and left sides.

Surface Anatomy of the Lung

Ant. Chest

Ant. Chest Inspection (5S) Symmetrical chest movement (decrease) Shape of the chest Scar Prominent veins in SVC obstruction Subcutaneous emphysema

Ant. Chest What is Paradoxical breathing? What are the causes of unilateral decrease chest movement? What are the causes of bilateral decrease chest movement?

Ant. Chest Palpation Trachea Centralized OR displaced. Normally, trachea is slightly displaced to the right side. What is Tracheal Tug? What are the causes of trachea displacement toward the side of lung lesion? What are the causes of trachea displacement away from the side of lung lesion?

Thumbs move symmetrically apart for 3-4 cm Ant. Chest Palpation Chest Expansion Apical Supra mammary Infra mammary Inspiration Thumbs move symmetrically apart for 3-4 cm

Ant. Chest Palpation Apex beat Site Size Character What are the causes of apex beat displacement toward the side of lung lesion? What are the causes of apex beat displacement away from the side of lung lesion? What is the lung disease causes of impalpable apex beat ?

Ant. Chest Palpation Tactile Vocal Fremitus Sites Use ulnar side of the hand. Ask the patient to say 99 in Eng. Or 44 in Arab. Move in zigzag and compare both sides. Comment as: equal, decrease, or increase TVF. Sites Supra clavicle Infra clavicle Supra mammary Infra mammary Upper axillary Lower axillary

Ant. Chest Palpation Tactile Vocal Fremitus What are the causes of decrease TVF? What are the causes of increase TVF?

Ant. Chest Palpation Ribs For tenderness

Ant. Chest Palpation Trachea Chest Expansion Apex beat Tactile Vocal Fremitus Ribs

Ant. Chest Percussion Sites Supra clavicle clavicle Infra clavicle Supra mammary Infra mammary Upper axillary Lower axillary Move in zigzag and compare both sides

Ant. Chest Percussion Comment as: Resonant ………….. Hyper resonant …….. Dullness …………..... Stony Dullness ……... Normal Pneumothorax Pneumonia Pleural effusion

Ant. Chest Auscultation Sites Supra clavicle = Apical Infra clavicle Supra mammary Infra mammary Upper axillary Lower axillary Move in zigzag and compare both sides

Ant. Chest Auscultation Comment on: Breath sounds, equal, decrease, or absent Quality of breath sounds, vesicular vs. bronchial Added sounds, wheezing, crackles Vocal resonance, equal, decrease, or increase Ask the patient to say 99 in Eng. Or 44 in Arab

Ant. Chest Auscultation Quality of breath sounds No gap Insp > Exp Quality of breath sounds Vesicular breathing …Normal Bronchial breathing …Consolidation Gap Insp = Exp

Ant. Chest Auscultation Added breath sounds Wheezing… Asthma Crackles… Fine……… Medium… Coarse…… Asthma Lung fibrosis LVF, pneumonia Bronchiectasis

Ant. Chest Auscultation Vocal Resonance What are the causes of decrease vocal resonance? What are the causes of increase vocal resonance?

Ant. Chest Auscultation What is Aegophony? What is Whispering Pectoriloquy? What is the indication of silent chest in asthmatic patient?

Post. Chest

Post. Chest Ask the patient to sit at the edge of the bed and you face his/her back. Ask the patient to make cross his/her arms on front chest to rotate the scapula anteriorly.

Post. Chest Inspection Shape of the chest Scar

Thumbs move symmetrically apart for 3-4 cm Post. Chest Palpation Chest Expansion Basal Thumbs move symmetrically apart for 3-4 cm

Post. Chest Palpation Tactile Vocal Fremitus Sites Supra scapular Intra scapular Infra scapular basal Upper axillary Lower axillary Move in zigzag and compare both sides

Post. Chest Palpation Chest Expansion Tactile Vocal Fremitus

Post. Chest Percussion Sites Supra scapular Intra scapular Infra scapular basal Upper axillary Lower axillary Move in zigzag and compare both sides

Post. Chest Percussion Comment as: Resonant ………….. Hyper resonant …….. Dullness …………..... Stony Dullness ……... Normal Pneumothorax Pneumonia Pleural effusion

Post. Chest Auscultation Sites Supra scapular Intra scapular Infra scapular basal Upper axillary Lower axillary Move in zigzag and compare both sides

Post. Chest Auscultation Comment on: Breath sounds, equal, decrease, or absent Quality of breath sounds, vesicular vs. bronchial Added sounds, wheezing, crackles Vocal resonance, equal, decrease, or increase Ask the patient to say 99 in Eng. Or 44 in Arab

Pemberton’s Sign

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