Review on

Physical
Examination
CHEST, CARDIAC AND NEURO
Content

▪ Chest Examination
▪ Cardiovascular Examination
▪ Neurological Examination
Chest Examination
Chest Examination

▪ Physique and gait ▪ Venous pulses

▪ Voice ▪ Cyanosis or pallor

▪ Breathlessness ▪ Swollen face

▪ Clubbing of the fingers ▪ Use of accessory respiratory muscles

▪ Tobacco staining of fingers ▪ Lymph nodes

▪ Bruising and/or thinness of skin

Chest Examination

Observing the chest Signs to look for in the hands

▪ Clubbing
▪ Rate of respiration
▪ Pallor

▪ Rhythm of respiration ▪ Warm, well-perfused palms (CO, retention)

▪ Cyanosis
▪ Chest expansion
▪ Tremor

▪ Symmetry ▪ Tobacco staining

▪ Bruising and/or thin skin

▪ Surgical scars
▪ Pulse rate and character
Features to note in assessing the shape of the chest

▪ Kyphosis (forward bending)

▪ Scoliosis (lateral bending)

▪ Flattening

▪ Overinflation

▪ Previous surgery causing asymmetry such as thoracoplasty

Points to note on palpation of the chest

▪ Swelling

▪ Surgical emphysema

▪ Pain and tenderness

▪ Tracheal position

▪ Cardiac impulse

▪ Asymmetry

▪ Tactile vocal fremitus

Causes of pain and tenderness in the chest

▪ A recent injury of the chest wall or inflammatory conditions

▪ Intercostal muscular pain – as a rule, localized painful spots can be

discovered on pressure

▪ A painful costochondral junction

▪ Secondary malignant deposits in the rib

▪ Herpes zoster before the appearance of the rash

Points to note on percussion of the chest

▪ Resonance

▪ Dullness

▪ Pain and tenderness

Points to note on auscultation of the chest

■ Vesicular breath sounds – normal breath sounds

■ Bronchial breath sounds – consolidation

■ Added sounds:
– pleural rub – associated with infection

– wheezes – asthma, COPD, infection, cardiac failure

– crackles – pulmonary fibrosis, cardiac failure, COPD

▪ Observe the patient generally and the ▪ Assess the jugular venous pressure (JVP).

surroundings. Look for any medicine, sputum

▪ Inspect the chest movements and the anterior
pots, inhalers, nebulizers or, for example, CPAP
chest wall.
machine around the patient’s bed. Is the patient
▪ Feel the position of the trachea and check for
using oxygen – if so, how much, what is the
axillary lymphadenopathy.
rate?

▪ Feel the position of the apex beat.

▪ Ask the patient’s permission for the examination

and ensure he is lying comfortably at 45°. ▪ Check the symmetry of the chest movements by

▪ Examine the hands and take the pulse. palpation.

▪ Percuss the anterior chest and axillae.

▪ Count the respiratory rate.
▪ Sit the patient forward:
▪ Inspect the posterior chest wall.
▪ Check for cervical and supraclavicular
lymphadenopathy.
▪ Percuss the back of the chest.
▪ Listen to the breath sounds.
▪ Check the vocal resonance.
▪ Check the tactile vocal fremitus.
▪ Check for sacral oedema.
If you are examining a hospital inpatient, always
take the opportunity to turn the pillow over before
lying the patient back again; a cool, freshened
pillow is a great comfort to an ill person.
▪ Listen to the breath sounds on the front of the
chest.
▪ Check the vocal resonance.
▪ Check the tactile vocal fremitus.
▪ Check for pitting oedema of the ankles.
Cardiovascular
Examination
Cardiovascular Examination

▪ Routine for the cardiovascular system examination

▪ Inspect the face, eyes and mucous membranes
▪ Wash hands
▪ Inspect the chest for scars and pulsations
▪ Introduce yourself to patient

▪ Recline patient at 45°
▪ Observe general appearance – comfortable, breathless, pale?
▪ Inspect the hands for clubbing, splinter haemorrhages, nicotine staining
▪ Examine the radial pulse(s) for symmetry, rate, rhythm, character
▪ Assess the position and character of the apex
beat
▪ Palpate the praecordium for heaves and thrills

(collapsing?) ▪ Auscultate the heart

▪ Measure the blood pressure
▪ Auscultate the lungs
▪ Assess the height and waveform of the JVP

▪ Examine the carotid pulse character (slow rising?) and volume

▪ Examine the ankles and sacrum for oedema
(Corrigan’s sign?)
▪ Examine the peripheral pulses
Cardiovascular Examination

Routine for auscultation of the upper left sternal edge

heart
■ Auscultate at apex with
diaphragm
■ Reposition patient on left side
– ‘Please turn onto your left side’
(pulmonary stenosis, pulmonary
regurgitation, patent ductus
arteriosus)
■ Auscultate with diaphragm at
upper right sternal edge (aortic
stenosis, hypertrophic

■ Listen with diaphragm (mitral cardiomyopathy)

regurgitation) and then bell
■ Sit patient forward. Auscultate
(mitral stenosis)
with diaphragm at lower left

■ Return patient to original sternal edge in held expiration

position, reclining at 45° (aortic regurgitation)

– ‘breathe in … breathe out

■ Auscultate with diaphragm at … stop’
lower left sternal edge (tricuspid
regurgitation, tricuspid stenosis, ■ Auscultate over the carotid
ventricular septal defect) arteries (radiation of murmur of
aortic stenosis, carotid artery
■ Auscultate with diaphragm at bruits)
Neurological Examination
Neurological Examination

Objectives:
(1) mental status

(2) cranial nerves

(3) motor system

(4) reflexes

(5) sensory system

(6) coordination, station and gait.

Equipment needed:
▪ Reflex hammer

▪ 128-Hz tuning fork.

▪ Ophthalmoscope.

▪ Pocket eye chart (for near vision testing)

▪ (Cotton swabs, tongue blades, and safety pins will be provided for you).
Mental status,

▪ Level of awareness.

▪ Attentiveness: Is the patient paying attention to you and your questions or is he distractible and

requiring re-focusing?

▪ Orientation: to self, place, time. Disorientation to time typically occurs before disorientation to place or

person. Disorientation to self is typically a sign of psychiatric disease.

▪ Speech & language: includes fluency, repetition, comprehension, reading, writing, naming.

▪ Memory: includes registration and retention.

▪ Higher intellectual function: includes general knowledge, abstraction, judgment, insight, reasoning.

▪ Mood and affect

cranial nerves
Motor system

(1) patterns of muscle atrophy or hypertrophy,

(2) assessment of muscle tone (e.g., spastic or clasp knife, rigid or lead pipe, flaccid) with
passive movement of joints by the examiner,

(3) disturbances of movement (e.g., the slowness and reduced spontaneity of movement in
parkinsonism),

(4) endurance of the motor response (e.g., the fatigability of myasthenia gravis),

(5) whether any spontaneous movements are present (e.g., fasciculations or brief twitches
within the muscle).

(6) Strength of proximal and distal muscles in all limbs should be assessed.
Reflexes
Sensory system

▪ Superficial sensation
▪ Pain

▪ Temperature

▪ Deep sensation
▪ Pressure

▪ Position sense

▪ Vibration
Coordination, station and gait.

▪ finger-to-nose (patient alternately touches your outstretched finger and his

nose)

▪ Heel-knee-shin (patient runs the heel of one foot down the shin of the other)

▪ Rapid alternating movements (patient alternately taps the dorsal and

plantar surface of one hand onto the other hand)

▪ Finger or toe tapping.

▪ Walking requires proper functioning of the cerebellum and motor, sensory,

and vestibular systems as well as a whole host of reflexes
Meningeal Signs

▪ Neck stiffness often accompanies the meningeal irritation of

meningitis or subarachnoid hemorrhage.
▪ Brudzinski’s and Kernig’s