Clinical Examination Dr Osama Mahmoud

DIAGNOSIS

I

~ Aetiological if possible e.g. T.B

~ Anatomical (The affected lobe).

~ Functional i.e.

of

SEGMENTS OF THE LUNGS

I

(A) The

ri

ht lung: Composed of 3 lobes:

1. Upper

lobe:

(3 segments)

Apical, anterior

and posterior.

2. Middle

lobe:

(2 segments)

Medial and lateral.

3. Lower

lobe:

(5 siments)

Superior, anterior, posterior, medial and lateral.

N=)JIilt¥Jt:iill!ilcd Composed of 2 lobes:

1. Upper

lobe:

Proper: (2 segments)

apico-posterior

and anterior.

2. Lower

Lingula: (2 segments)

superior and inferior.

lobe:

(4 segments).

Superior,

antero basal, lateral basal and post basal.

I

TYPES OF BREATHING

1·,· Chen e·

stockes breathin

: it is a type

of periodic

'breathing

There are periods of apnea

for about

1/2

minute

followed

by hyperapnea for 8 -

10 cycles

then

apnea, and so

on. It

is due

to depression

of

respiratory

center with

sensitivity to CO2.

Hyperventilation

~

washes CO2~

apnea ~

C02 retension

~ Hyperventilation

and so on with a crescendo-decrescendo

pattern

Causes:

1. Depression

of R.C. by opiates,

barbiturates

or alcohol.

2. Depression

of R.C. by hypoxia

or ischaemia

as in: vertebro-basilar

insufficiency, advanced H.F. pontine

damage

and cerebral

infarction.

3. It occurs during

sleep in some normal persons?

11-Blot's

Breathin

: It is a variant

of cheyne-stokes

breathing

Occurs

in meningitis, head injuries and medullary

compression.

There

is periodic breathing but it lacks the typical

crescendo-decrescendo

,

>

Bronchial

breathinq is glottic due to transmission of the glottic hiss

through bronchial

tree to an area with alveoli

out of function e.q.: consolidation tF.:cause

the: normal

rc

.ji

Ii .odify the bronchial sound

into vesicular.

Chest sheet

I

MECHANICS OF RESPIRATION

coating

the large

airways, this

mechanism is

responsible for

the generation of

coarse

crepitations

e.g. in cases of acute and chronic bronchitis.

(2) Sudden

equalization of intra

airway pressure

occurs during

sudden reopening

of partially

collapsed

small airways. This

mechanism

occurs when

small

airways

are compressed

by high interstitial pressure

due to scarring

(interstitial fibrosis)

or

. fluid in the

interstitium.

This mechanism

is responsible

for

the

production

of fine

prepitations

in

cases

of

interstitial

pulm

fibrosis,

or

interstitial

edema

due

to

pneumonia

or PVC.

(3)

Fluttering

of

the airway

wall,

this

occurs

whenever

air

flows rapidly through

a

narrow

airway

e.g. bronchospasm

or bronchial secretions,

this simply sucks in the

airway

wall

itself producing

rhonchi.

(4)

Rubbing

of

inflamed

pleural

surfaces

when

the

two

pleural

layers

become

rough

by

an

inflammatory

process

and

covered with

fibrinous

layers producing

leathery sound

(pleural

rub) which

can be heard during

inspiration

and expiration.

~-

·'+<L~'1'-:Yi'-. - ?'~'':"" "::',":':

,:,:;--"':~r~, .-,"':- "'::1('-,"'"

:':'.'

:,:",:" ",/:' ' '):::.

_

"

' "-,- -

_ ::f:"

,:,:',l - ,,,-:-- --

>-.;

,":'"

:: -

:.:

::"

,<:~>.-"

",)~:

--\;:,:,:':"

:':':.:~

/~.J:Th:'IP!~~~~tio~s

of, bro~cbiectasisJs

not generated

d~e to the bub~ling

of air through

','.;: thirf~~e~retions~ In bronc~iectasis the

airways

,are abnormally

dilated

as a result

of

.th~d~~truction.: qf elastic

and muscular

components

of the wall. So the bronchial

wall

. ';tend~'tc"'c~l\;ps~

in expiratio~

and then reopen suddenly

in inspiration

producing

the

h~r. c~ep(tations~that'do not clear with cdughing.:~.

:OiFcirly'or rnid'inspiratory crepitations

are produced by.mechanism

1 (as above), while

'/ -late inspiratory

c;epitations

are produced by mechanism

2 (as above).

.

-----

Central

I +++

IIDull

Bronchial

Crepitations

-

-----

Central or

+++

Dull

Bronchial

Crepitations

Ipost-tussive

pulled

suction

-----

Pulled.

-----

Dull

Diminished

-

-

-----

Pulled

+ or--

Dull

Diminished

ICreoitationsCrepitations

-

-----

Central

-----

Normal

Harsh. V

IRhonchi

-

.

-----

Central

-----

Hyper resonant

Harsh. V

Rhonchi

-

-----

Central

----

Normal

Vesicular

Rub

-

----

Pushed

-----

Stony dull

Diminished

-

-

-----

Pushed

I -----~Tympanitic

Diminished

-

Coin test

-----

Pushed

I ----~Shifting dullness

Diminished

I

-

ISuccusion

splash

~

The

superficial inguinal ring lies just above the pubic tubercle.

~

The

linea semilunaris

is a line which

corresponds

to the

lateral border

of the rectus

abdominis muscle,

it extends from

mid inguinal

point

towards the

mid clavicular

point.

IMPORTANT VERTEBRAL LEVELS

I

~

Xiphisternal

Joint ~

Tgff 10.

!3. Transpyloric

plane ~

L1 (midway between the suprasternal notch and symphysis

pubis).

L3

~

Subcostal plane ~

~,

Plane of the highest

points of iliac crests (supracristal plane) ~ L4.

~

Intertubercular plane

~ Ls .

'& The

inferior

border:

Passes along a line which extends from

a point one finger's

breadth

below the

right

costal

margin at the

side of the trunk

(10th rib) to the point

of the apex

of the

heart. (5th left intercostal

space

3.5 inches

from middle line just

below the nipple).

s" rib right M.C.L. _To_+

'& The

superior

border:

5th I.C. space in the M.C.L.

TO.

yth

rib in the

right M.A.L.

To

9th rib in the scapular

line.

'& The

right

surface

of the

liver extends from the

level of the

yth

rib in the mid axillary

line to the level of the

11th rib in the mid axillary

line (or just

below io" rib).

'& Normally

the

left lobe

is one patient's hand breadth below

xiphisternum.

Costal

~-~+

Gallbladder

margin

Outer

border

..---•...+- Umbilkus

Anterior

right

rectus

superior

sheath

spine

(A) Anterior

surface

markings:

~

As a rule, the right kidney

is about 1.5 cm lower than the left so the upper end of the

right kidney reaches the

11th intercostal space while the upper end of the left

kidney

ascends

higher to reach the 11th rib itself.

'i3.

The hilum of each kidney 6 cm from the median plane.

II The different

parts of viscera in different regions of the abdomen: II

• The abdomen

is divided

into nine regions by the

intersection of imaginary planes,

two horizontal and two

sagittal,

•

The

upper

horizontal

plane

is the transpyloric plane (L 1).

•

The

lower

horizontal

plane

is the intertubercular

plane (L5).

Ahdomen sheet

(4) Umbilical region:

o Third part of the duodenum.

@ Transverse colon.

o Caecum.

(j) Appendix and the end of the ileum.

ABDOMINAL CASE

I

* Appetite.

* Dysphagia.

* Belching

* Nausea.

* Vomiting.

* Water brash

* Haematemesis.

* Melena.

* Halitosis.

* Ptyalism.

* Xerostomia.

* Epigastrc pain.

* Diarrhea.

* Constipation.

* Dysentery.

* Flatulence.

* Bleeding per rectum.

* Jaundice

* Genitourinary symptoms.

* Hiccough

* Parorexia

* Dyspepsia

(it can be considered

as an upper GIT symptome)

• Acoria

Loss of appetite

(anorexia):

a- Anorexia

nervosa.

b- Depression.

•

c- Viral hepatitis.

d- Uremia.

e- Gastritis.

f- Malignancy

1(3) Nausea

and

vomiting:11

® Is vomiting heralded by nausea or does

it occur without

warning.

® Does it relieve the pain or not.

® Amount (huge in pyloric

obstruction).

® Color e.g coffee grounds

in as in haematemesis, yellow

colour indicates

bile in severe vomiting.

® Odour e.g. foul smell in ulcerated cancer

stomach.

1(4} Haematemesis

and melena:1

o Haematemesis

= vomiting

of blood. (Ask about color, amount, number of attacks

and ocurrance

of hypotension or shock)

o Melena = Passage

of dark tarry soft offensive stool.

- Spurious

melena

due to ingestion of blood of epistaxis or haemoptysis.

Important causes:

a- Peptic ulcer.

b- Esophageal

varices.

c- Acute gastritis especially

caused

by drugs as aspirin - cortisone.

d- Cancer stomach, cancer oesophagus.

e- Blood diseases

as leukemia - purpura.

a- Frequency / day.

b- Relation to meal (secretory

diarrhea occurs even with fasting, see later).

c- If associated with

pus, mucous, blood or tenesmus

= dysentery.

Tenesmus means

sense of incomplete evacuation.

d- Colour of stool e.g.: bloody

as in ulcerative colitis,

pale as in steatorrhoea, tarry

(melaena)

e- If the stool is of large volume and not excessively

frequent suggesting small

bowel disease.