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 • Breathing patterns
– Pectus carinatum – Apnea
– Pectus excavatum – Biots
– Kyphosis – Cheyne stokes
– Scoliosis – Kussmauls
– Kyphoscoliosis – Apneustic
– Flail chest – Paradoxical
– Asthmatic
• Central cyanosis • 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