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36
1 General History Taking andGeneral Examination
a
Tongue pushing
against cheek
Fig. 1.25 (a, b) Clinical examination of hypoglossal nerve
Tongue pushing
against cheek
while examiner
palpating
the tongue against each cheek
while the examiner tries to dislodge it.
Cranial nerves with their functions
No Name of nerve Functions of nerve
1 Olfactory Smell function
2 Optic Vision
3 Oculomotor Movement of eyeball
4 Trochlear Movement of eye ball
5 Trigeminal Clinching, sensation
over face
6 Abducent Lateral movement of
eyeball
7 Facial Movement of face
8 Vestibulocochlear Hearing and balance
9 Glossopharyngeal Movement of uvula
10 Vagus Vocal cord movement
11 Spinal accessory Shrugging of
shoulders
12 Hypoglossal Movement of tongue
2. Cardiovascular system (CVS)
(a) Inspection:
• Jugular venous pressure—It is
dened as the height of the waveform in centimetres above the
angle of sternum, normal jugular
venous pressure (JVP) is <4cm. In
clinical examination, the JVP is the
most mysterious. The JVP should
be examined in 45° reclination
(head elevated), and only the inter-
b
nal jugular vein should be used
because IJV joins the superior vena
cava at a 180° angle. Two things
are very clear: (1) JVP is a very
useful in diagnosing right-sided
heart failure and in differentiating a
cardiovascular cause of acute
shortness of breath (right ventricular failure, pulmonary embolism)
from an intrinsic pulmonary cause
(asthma, chronic obstructive pulmonary disease) and (2) the exact
height of the JVP is a poor guide to
central venous pressure.
(b) Palpation—The apex of heart can be
palpated in fth intercostal space on
left side.
(c) Auscultation—The purpose of aus-
cultation of heart to assess the heart
sound and added sound. It starts with
listening of the heart sounds S1 and
S2 at left fth intercostal space, then
examiner should also listen over the
second right intercostal space (aortic
area) and second left intercostal
space (pulmonary area). Examiner
should use diaphragm (better for
higher pitch) and bell (better for
lower pitch) over left lower sternal
edge. If in doubt, use both. The bell
of stethoscope should be used to hear
an abnormality over the aortic or pul-
1.2 Examination ofPatient
37
monary areas. During auscultation of
heart, the volume (normal, diminished, loud) of S1, S2 and added
should be noted.
• Heart sound variations
– Physiological splitting of the
second heart sound—It is
heard when the sound of aortic
valve closure (A2) occurs earlier than that of pulmonary
valve closure (P2). It occurs in
inspiration and is more common in the younger and also
caused by increased venous
return and negative intrathoracic pressure.
– Reverse splitting of the sec-
ond heart—It is heard in conditions when aortic valve
closure is delayed, such as left
bundle branch block or paced
right ventricle, or when pulmonary valve closure occurs early,
for example, B form of Wolff–
Parkinson–White syndrome.
The another condition known
as wide xed splitting of the
second heart sound occurs in
atrial septal defect.
– Third heart sound—It is low-
pitch sound, heard soon after
the second heart sound. It is
thought to be due to rapid,
high-volume lling of the left
ventricle. Third heart sound
can be pathological (i.e., left
ventricular failure) or
physiological (i.e., athletic
heart, pregnancy).
– Fourth heart sound—It is
low-pitch sound heard just
before the rst sound also
known as atrial gallop. This is
caused by hypertensive heart or
diastolic heart failure.
• Added sounds
– Murmurs—It is abnormal
sound heard during the auscul-
tation of heart as whooshing,
swishing, blowing or rasping
sound. If murmur is present,
examiner should rst establish
whether it occurs in systole or
diastole.
– Opening snap—It is a high-
pitch sound heard after the second heart sound. Represents a
diseased mitral valve opening
to a stenotic position. It is present in diseases like mitral stenosis, severe mitral
regurgitation.
• After auscultation of heart—
The base of the lungs for the ne
inspiratory crackles of pulmonary
oedema. Liver should be palpated
if examiner is suspicious of rightsided cardiac pathology, liver can
be enlarged and possibly pulsatile
in cases of right ventricular failure
or tricuspid valve disease. Also,
check the patient for pedal
oedema.
3. Respiratory system
Positioning of the patient—For examina-
tion of chest, the patient should be undressed
to the waist. The examination is easy to perform with the patient sitting over the edge of
the bed or even on a chair If he or she is not
acutely ill.
Examination of respiratory system—
There are four cardinal steps of chest examination (inspection, palpation, percussion and
auscultation).
(a) Inspection of chest: Skin of chest wall
should be inspected for scars, cutaneous
swellings, marks and spots. Subcutaneous
lesions may be visible as swelling, including metastatic tumour nodules, neurobromas and lipomas. Look for vascular
anomalies such as spider naevi and
enlarged arterial vascular channels, found
in coarctation of the aorta but venous vascular channels in present superior vena
cava obstruction. All the clinical ndings
in supraclavicular area, infraclavicular
38
Normal
Barrel Chest* Scoliosis*
1 General History Taking andGeneral Examination
area, mammary region, axillary region,
infra-axillary region, suprascapular
region, interscapular region and
infrascapular region should be compared
on both sides.
• Position of trachea—Trachea is
located in midline in lower neck. If it
is displaced to one side, there is undue
prominence of sternal head of sternocleidomastoid muscle is seen on
inspection on same side. This sign is
called Trail’s sign. This is caused by
apical tuberculosis or lung brosis,
thyroid tumour.
• Position of apex impulse—The apex
impulse is seen in fth intercostal
space just lateral a line drawn from
mid clavicular line. The apex impulse
can be shifted to side of mediastinal
shift.
• Appearance of the chest wall/
shape—Normal chest wall is bilaterally symmetrical and elliptical in
cross-section. The anteroposterior
diameter is less than the lateral
diameter.
– Abnormalities (deformities) of
chest wall (Fig. 1.26)
Barrel chest—When the anteroposterior diameter is more than
the lateral diameter, the chest is
described as ‘barrel-shaped’.
Pectus carinatum—This is also
known as the Pigeon chest.
There is a localized prominence
of the sternum and adjacent costal cartilages often accompanied
by indrawing of ribs to form
symmetrical horizontal grooves
(‘Harrisons sulci’) above the
costal margin.
Pectus excavatum—It is also
known as funnel chest. It is the
exaggeration of the normal hollowness over the lower end of
the sternum. It is a developmental defect.
Kyphosis—It is an exaggerated
anterior curvature of the spine.
Scoliosis—It is lateral curvature
of spine.
Kyphoscoliosis—If both deformities are present together. It
may be idiopathic or secondary
to childhood poliomyelitis or
spinal tuberculosis. In this con-
Fig. 1.26 Abnormalities
of the chest wall
Pectus
Carinatum
Pectus
Excavatum
Kyphosis*
1.2 Examination ofPatient
39
dition, the ventilator capacity of
the lung reduces and the work of
breathing increased.
• Movement of the chest
– Symmetry of chest wall move-
ment—Chest to be inspected for
movement of the two sides (both
upper and lower parts). The movement of the normal chest is bilaterally symmetrical and equal.
– Impairment of movement—The
impairment of chest wall movement can be present on either one
or both sides. Unilateral impairment suggests disease of the underlying lung or pleura on the affected
side such as pneumonia, pleural
effusion, pneumothorax, lung collapse, atelectasis, unilateral bronchial obstruction or foreign body
lodged in one of the mainstem
bronchi. Bilateral impairment can
be caused by chest wall disorders,
diaphragm disorders.
– Chest indrawing—Chest indrawing
or subcostal retraction is dened as
abnormal inward movement of the
lower chest wall when a person
breathes in. It is a sign of respiratory distress, occurs due to the contraction of the accessory thoracic
muscle any condition caused by
reduced compliance of lung (pneumonia) and increased airway resistance (asthma).
– Chest retraction/intercostal retrac-
tion—It is the retraction (sucking
in) of intercostal muscles between
the ribs during inspiration. It is due
to reduced air pressure inside chest
and present if the upper airway (trachea) or small airways of the lungs
(bronchioles) become partially
blocked.
• Breathing pattern—Breathing pattern is described in terms of rate,
rhythm type and depth of breathing.
– Rate—It is dened as the number
of breathings per minute during
rest. The normal rate is 12–20
breath per minute.
Tachypnoea—Respiratory rate
is more than 20 per minute.
Bradypnea—Respiratory rate is
less than 12 per minute.
Apnoea—If there is an absence
of breathing for more than 15s
duration.
– Rhythm—A regular rhythm means
it is evenly spaced and constant in
frequency. Irregular rhythm means
it not evenly spaced and constant in
frequency, for example, Chyne
stoke’s breathing (alternating periods of apnoea and hyperventilation), Kussmaul breathing, agonal
respiration, etc.
– Type of breathing
Normal (Eupnoea-)—Normal
breathing is thoraco-abdominal in
woman and abdomino-thoracic in
men.
– Depth of breathing
Abnormal deep breathing
Deep sighing breathing—
Kussmual’s breathing is dened
as rapid, laboured breathing. It is
a sign of metabolic acidosis, for
example, diabetic keto-acidosis
(DKA), uraemia, pre-eclampsia,
eclampsia, anxiety.
Forced expiration—It is a termed
when expiration has prolonged
expiratory phase with visible use
of accessory muscles of the neck
and intercostals muscles. It is
present in asthma, chronic bron-
chitis, pulmonary emphysema.
Forced inspiration—It is a
termed when inspiration has
prolonged inspiratory phase
with visible use of accessory
muscles of the neck and inter-
costals muscles. It is present in
40
1 General History Taking andGeneral Examination
brosis, pulmonary oedema, or
in blockage of the large airways
such as trachea or larynx.
Abnormal shallow breathing—
Abnormal shallow breathing can
be shallow, rapid breathing and
shallow slow breathing.
(b) Palpation: Palpation done to conrm the
ndings of inspection, and add other
additional information of diagnostic.
• Tenderness—Palpation is done at the
site of pain. Tenderness can be caused
by injury, inammatory condition,
muscular pain, rib fracture, inammation of pleura.
• Mass/swelling—A mass is to be palpated to know site, temperature, tenderness, size, consistency, surface,
mobility, etc.
• Position of trachea—It is conrmed by
palpating trachea from superior to
inferior direction starting from thyroid
notch to suprasternal notch in slightly
exion of the neck. The index nger is
then inserted in the suprasternal notch
and the tracheal ring is felt. Slightly
shift of trachea to the right is normal.
Trachea can be shifted to one side by
tumour in upper mediastinum, mediastinal shift, thyroid tumours (Fig.1.27).
• Deviation of trachea (Table 1.12):
• Causes of abnormal tracheal
deviations:
• Tactile vocal fremitus (vocal fremi-
tus)—It is the transmission of voice
sound from central airways to the
chest wall. It is a vibration felt by the
hand when the patient is asked to
repeat ninety-nine or one-one-one, by
putting the vocal cord into action.
– Procedure to palpate TF—Ask the
patient to say ninety-nine several
times in normal voice and the posterior, anterior and the lateral chest
areas including the apices are palpated for presence, absence and
symmetry of TF on both sides. The
sites of increased, decreased or
absent TF are located
– Causes of altered vocal fremitus
– Causes of Increased TF—Lung
consolidation, lung brosis
– Causes of decreased to absent TF—
Obstructed bronchus, chronic
obstructive pulmonary disease
(COPD), pneumothorax, pleural
a
Fig. 1.27 (a–c) Methods of palpation of trachea
Table 1.12 Causes of tracheal deviation
Deviation towards the side of lesion Deviation away from the side of lesion
Upper lobe lung collapse
Upper lobe lung brosis
Pneumonectomy
b
Tension pneumothorax
Massive pleural effusion
c
1.2 Examination ofPatient
41
effusion, haemothorax, Pleura
thickening
• Chest expansion/movement of chest
wall—Place the ngertips of both
hands on either side of the lower rib
cage so that the tips of the thumbs
meet in the mid line (done either on
the anterior or posterior side of chest),
then the patient is asked to breadth
deeply. Posteriorly, at the level of and
parallel to the tenth ribs. If one thumb
remains closer to the midline indicates
that there is a diminished expansion of
the chest on that side.
• Conrmation of Apex impulse—
Displacement of the apex thrust can be
demonstrated by palpating rst with
palm of the hand and later with the ngers to determine its exact site. Apex
beat deviation (and deviation of cardiac dullness) is the main indications
of the shift of the lower mediastinum.
• Tracheal descent—Tracheal descent
with inspiration can be seen in the
suprasternal region.
• Measurement of chest expansion
(Fig. 1.28)—Normally, both sides of
the thorax should expand equally during tidal and maximal inspiration. The
assessment of expansion of the upper
lobe is done by observing clavicle
from behind during tidal breathing. A
decrease or diminished chest movement on one side indicates abnormality on the same side. To assess
expansion of the lower lobe, the examiner places his hands rmly on the
chest wall with ngers extending
around the side of the chest and thumbs
of both hands should almost meet in
the midline, hands should be free to
move with respiration. Now, ask the
patient to take a deep breath, thumbs
should move symmetrically apart at
least 5cm. Reduced expansion on one
side indicates abnormality on that side,
for example, pleural effusion, lung or
lobar collapse, pneumothorax and unilateral brosis. Bilateral reduction in
chest wall movement in common in
advanced COPD and diffuse pulmonary brosis.
(c) Percussion—Percussion is performed in
sequence over equivalent area on the both
sides of the chest to listen the pitch and
loudness of the percussed note and to feel
post-percussive vibrations. The main purposes of respiratory percussion are to
determine the state of underlying tissue,
such as lungs or pleura, by the degree of
resonance of note elicited and sense of
resistance encountered second is to delineate or dene the boundaries or borders
of the lungs.
Fig. 1.28 Examination
of chest wall movement
Examination of chest wall movement
42
1 General History Taking andGeneral Examination
• Area of percussion (Fig.1.29):
– Anterior chest wall—It is done
over clavicle, supraclavicular
region and second to sixth intercostal space.
– Lateral chest wall—Percuss from
fourth to seventh intercostal spaces
(Fig.1.29).
– Posterior chest wall (Fig.1.29)
Interscapular region
Fig. 1.29 Areas of percussion
Infrascapular region up to the
eleventh rib
Supraclavicular (above the spine
of the scapula)
• Types of percussion notes and diagnosis (Table1.13)
Denition of different types of
dullness (Table 1.14)
(d) Auscultation: Auscultated of the chest is
done to assess the type, intensity and
Table 1.13 Causes of various types of percussion note
Type of percussion note Lesions
Tympanitic Hollow viscus
Subtympanic (skodiac resonance or bony quality) Above the level of pleural effusion
Hyper-resonant Pneumothorax
Resonant Normal lung
Impaired Pulmonary brosis, cavity with surrounding brosis
Dull Consolidation, collapse, pleural thikening
Stony dull Pleural effusion, empyema, parenchymal lung disorder with
pleural thickening
Table 1.14 Different types of dullness
Crack pot resonance: This is a variety of tympanic resonance, which can be elicited normally over the chest of an
infant or child during the act of crying. It is found over a large cavity communicating with a bronchus
Tidal percussion: Percussion of the lower border of lung resonance, on each side, at the height of deep inspiration
and expiration, serves to determine the extent of diaphragmatic excursion. Restriction or diminution of movement
of the lower border of lung resonance, either unilateral or bilateral, during respiration, is suggestive of some disease
of the lung, such as pulmonary brosis
Straight line dullness: It is present in hydropneumothorax
Shifting dullness: This is done to demonstrate the shift of uid in pleural effusion and hydropneumothorax. In
hydropneumothorax shifting occurs immediately, whereas it is very slow in case of pleural effusion, but never with
an interlobar or loculated effusion
‘S’-shaped curve of Ellis: In moderate-sized effusion, the upper-most level of dullness is highest in the axilla and
lowest in the spine and tends to assume the shape of the letter ‘S’
1.2 Examination ofPatient
43
quality of the breath sounds as well as the
presence of extra, or adventitious sounds.
• Auscultatory Areas:
– Anterior—from an area above the
clavicle down to the sixth rib.
– Axilla—area up to the eighth rib.
– Posterior—above the level of the
spine of scapula down to the 11th rib.
• Breath sounds: Breath sounds are produced by the vibration of the vocal
cords due to the turbulent ow of air.
– The following features must be
observed in the case of breath
sounds
Intensity or loudness.
Quality or character, whether rustling, breezy, blowing or tubular.
Comparison of inspiratory and
expiratory elements of the
sound, from the point of view of
intensity, duration, duration or
length and pitch.
Presence or absence of intermediate pause, between inspiration
and expiration.
Presence of other sounds or
accompaniments.
– It may be normal and abnormal
Normal breath sounds—Three
types of normal breath sounds
are heard over the different parts
of lung.
Vesicular breath sound—This is
normal breath sound heard over
lung tissue (normal lung parenchyma), which is rather quite
low-pitched rustling sound without distinct pause (gap) between
the end of the inspiration and the
beginning of expiration.
Causes of diminished vesicular breath sound
Reduced conduction Reduced air ow
Obesity/thick chest
wall
Pleural effusion or
thickening
Pneumothorax
Generalized, e.g. COPD
Localized, e.g. collapsed lung
due to occluding lung cancer
Bronchial breath sound—This
normal breath sounds heard over
the trachea and two over main
bronchus, which is a harsh,
tubular, sound and becomes
inaudible just before the end of
inspiration, so that there is a gap
before the expiratory sound is
heard. The expiratory sound
lasts for most of the expiratory
phase. Types of bronchial
breathing are tubular, cavernous
and amphoric.
Types of bronchial sound and its causes
Tubular (high
pitched)
Pneumatic
consolidation
Collapse lung
Above pleural
effusion
Cavernous (low
pitched)
Thick-walled
cavity with
communicating
bronchus
Amphoric (low
pitched, with a high
tone and metallic
quality)
Large supercial
smooth-walled
cavity
Bronchopleural
stula
Tension
pneumothorax
Vesiculo-broncheal (Bronchovesicular) breath sound—
Normally heard in areas of the
major bronchi especially at the
apex of the right lung and the
sternal border.
– Added (adventitious) sounds—
Atypical (added, adventitious)
sounds are not alterations in breath
sounds but superimposed on breath
sounds
Crackles/rales—The interrupted, short-duration, nonmusical added sounds are called
crackles. It usually results from
loss of stability of peripheral airways, which collapse on expiration. With high inspiratory
pressure, air enters rapidly into
these distal airways with abrupt
opening of alveoli and small
bronchi, producing the characteristic crackling noise.
44
1 General History Taking andGeneral Examination
Table 1.15 Causes of crackle
Phase of inspiration Cause
Early Small airway diseases as
bronchiolitis
Middle Pulmonary oedema (medium)
Late Fine—Pulmonary brosis,
COPD, pneumonia
Coarse—lung abscess,
tubercular cavities
Biphasic Bronchiectasis (coarse)
Type of crackles:
Fine: They are less loud, short in
duration and arise from the
alveoli.
Coarse: They are low pitched,
loud and arise from the bronchus
and bronchioles.
Cause of crackle (Table 1.15)
Wheezes/ronchi—These are
continuous musical sounds
caused by ow through narrowed airways. Their signicance is the same whether they
are heard at a distance or only
through a chest wall. Wheezes
are often audible at the mouth as
well as through the chest wall.
Wheezes are generally more
prominent during expiration
than inspiration and reect the
oscillation of airway walls that
occurs when there is airow limitation. Wheeze is heard in bronchial asthma, bronchitis,
laryngeal spasm, tracheal brosis, congestive heart failure (cardiac asthma).
– Miscellaneous sound
Vocal resonance (Bronchophony,
Aegophony and Whispered pectoriloquy)—Vocal resonance is
an assessment of the density of
lung tissue, performed by auscultating the chest while speaking. Ask the patient to speak
normally (‘one-one-one’,
ninety-nine, etc.) while auscultating the chest wall.
Bronchophony—Sound of the
voice heard on auscultation over
a healthy bronchus and over
other portions of the chest in
case of consolidation of the lung
tissue.
Whispered Pectoriloquy—Ask
the patient to whisper ‘ninetynine’, or ‘arba arat’, several
times. Auscultate several symmetrical areas over each lung.
Only faint sounds or nothing
heard. If sound is heard clearly,
this is referred to as whispered
pectoriloquy present in
consolidation.
Aegophony—Voice sound has
nasal or bleating quality. Ask the
patient to say ‘ee’ continuously
while auscultating over several
symmetrical areas of each lung.
The examiner should hear a
mufed ‘ee’ sound normally. If
sound is heard like ay or aa then
ABNL. This is referred to as
‘E→A’ or Egophony present in
consolidation.
Pleural friction rub—Pleural
friction rub is heard as creaking
noise liked to that emitted by
compression of new leather. It
indicates inamed pleural surfaces rubbing against each other,
often during both inspiratory and
expiratory phases of the respiratory cycle. This is heard in
inammatory conditions of the
pleura (pleurisy) from adjacent
pneumonia or tuberculosis (TB),
pulmonary infarction. They are
not altered by coughing. They
are associated with pain.
Pleuro-pericardial rub: It is present in pleurisy adjacent to the
pericardium.
Succussion splash: Splashing
sound heard over the chest either
with stethoscope or unaided ear
1.2 Examination ofPatient
45
applied to the chest wall when
the patient is shaken suddenly
by the examiner. It can be heard
in hydropneumothorax, diaphragmatic hernia.
(e) Gastrointestinal tract system (GIT)—
The examination consists of Inspection,
Palpation, Percussion and auscultation.
Inspection—The abdomen is inspected
for signs like distension, mass, grey turner
sign (ecchymosis of ank and groin),
Cullen’s sign (periumbilical haemorrhage), presence of scar, pink purple
striae (Cushing syndrome), Caput medusa
(Vena cava obstruction).
Palpation—The examiner stands or
sits on right side with patients in supine
position, with the arms on the side of the
body and knee exed. There are three
stages of palpation that include supercial or light palpation, deep palpation
and organ palpation and should be performed in the same order. The palpation
of the abdomen is started from left iliac
fossa—hypogastric fossa—right iliac
fossa—right lumbar region—right hypochondrium—epigastrium—left hypochondrium—left lumbar region. Few
common ndings are tenderness of the
epigastrium may be due to gastritis or
early acute cholecystitis from visceral
nerve irritation, pulsatile mass from an
abdominal aortic aneurysm or abdominal wall defects, seen in muscle diastasis, and left lower quadrant tenderness
may be a presenting sign of diverticulitis. A mass in left iliac, if present, could
be due to a tumour of the colon, a left
ovarian cyst, or ectopic pregnancy. In the
elderly, due to impacted faeces.
Percussion—The patient should lie in
a supine position with the leg exed during percussion. It is important to appreciate tympany over air-lled structures such
as the stomach and dullness to percussion, which may be present due to an
underlying mass or organomegaly (e.g.,
hepatomegaly or splenomegaly). To
assess the size of the liver, percussion
should be done downward from the lung
to the liver, and then the bowel; the examiner may be able to demonstrate the
change in percussion notes from resonant
to dull and then tympanitic. To assess
shifting dullness, percussing is done from
the midline to the ank till the note
changes from dull to resonant and then
having the patient roll over on their side
towards the examiner and wait for 10s.
This allows any uid, if present, to move
downwards. The percussion should then
be repeated, moving in the same direction. If the percussion note changes to
resonant, shifting dullness is positive. The
renal tenderness can be appreciated at the
right and left costal-vertebral angles with
the patient sitting up.
Auscultation—This is the last step of
the abdominal examination. The diaphragm of the stethoscope should be
placed on the right side of the umbilicus
to listen to the bowel sounds, and their
rate should be calculated after listening
for at least 2min. Normal bowel sounds
are low-pitched and gurgling, and the rate
is normally 2–5/min.