History Taking & Chest
Examination
Dr. Waseem HAJJAR, MD. FRCS.
Assistant professor &
Consultant Thoracic Surgeon
A good history should be both:
 Concise.
 Cover the important points.
Rules:
1. Patient should be allowed to tell his history
in his own words.
2. Leading questions must be avoided unless
the information can’t be obtained by other
means
Questions:
1. Complete the immediate description.
2. Elucidate the vague points.
3. Fill in the gaps the history not mentioned by
patient.
4. Emphasize the important points.
Types of questions:
1. Neutral questions.
2. Simple direct questions (yes/No).
3. Leading questions.
WHAT SHOULD WE KNOW ABOUT
THE EXAMINATION OF THE CHEST?
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•
•
•
•
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HISTORY
SYMPTOMS
LANDMARKS
PERTINENT VOCABULARY
SIGNS
HOW TO PERFORM AN EXAM
HOW TO PRESENT THE INFORMATION
HOW TO FORMULATE A DIFFERENTIAL DIAGNOSIS
Personal data:
 Name.
 Age.
 Sex.
 Occupation.
 Residence.
The patients complaint:
A simple statement in the patients own words and its
duration.
HISTORY
Present History:
This means detailed history of the patients present
illness which must provide answer for the following
questions:
1.
Duration
2.
Mode of onset (acute, sub acute, chronic).
3.
Sequence of events:
I.
II.
III.
4.
Course (progressive, regressive or recurrent).
Appearance of new additional symptoms or
disappearance of others.
Treatment received during the course & response.
Analysis of each particular symptom.
History
 Acute/chronic disorder
 Preceding systemic disturbance
 Past medical history
 Drug history
 Social history
 Family history
 Occupational history
Past History:
 Childhood diseases.
 Trauma.
 Residences or travel abroad.
 Drug therapy.
 Operations.
THE HISTORY
FAMILY HISTORY
 EMPHYSEMA AT AN EARLY AGE - CONSIDER
ALPHA – 1 ANTITRYPSIN
 RECURRENT RESPIRATORY INFECTIONS AND
STERILITY IN A YOUNG ADULT MALE –
CONSIDER CYSTIC FIBROSIS, IMMOTILE CILIA
OR YOUNG’S SYNDROME
 PULMONARY NODULE AND HYPOXEMIA –
CONSIDER OSLER WEBER RENDU
Family History:
 Hereditary factor.
 Exposure to same etiological circumstances.
THE HISTORY
 OCCUPATIONAL - CHRONOLOGIC ORDER
 EXPOSURE :
BRAKE SHOES, PIPE FITTERS (ASBESTOS)
SANDBLASTING, QUARRY (SILICOSIS)
FARMING – (FARMERS LUNG)
MILITARY – (BERYLLIOSIS)
 TRAVEL- FAR EAST (PARAGONIMIASES)
SOUTH AMERICA (BRUCELLOSIS)
SOUTHWEST USA (COCCIDIOMYCOSIS)
 DRUGS – INTERSTITIAL LUNG DISEASE
(NITROFURANTOIN)
 HABITS – TOBACCO, NOSE DROPS, ILLICIT DRUGS
Habits:
 Smoking.
 Physical efforts.
 Addiction.
SYMPTOMS
History
 Dyspnoea
 Wheeze
 Cough
 Sputum
 Haemoptysis
 Chest pain
MAIN SYMPTOMS OF
PULMONARY DISEASE








COUGH
DYSPNEA
HEMOPTYSIS
CHEST PAIN – PLEURITIC
WHEEZING
CYANOSIS
SPUTUM PRODUCTION
SNORING
BRAIN
SKIN
KIDNEY
LUNG
LIVER
SPLEEN
HEART
DESCRIBE THE COUGH
 PRODUCTIVE – NONPRODUCTIVE
 ACUTE – CHRONIC
 TIME OF DAY
 PRECIPITANTS – RELIEF
 BLOODY – NON BLOODY
 BARKING – HACKY
COUGH
SYMPTOM
ETIOLOGY
MORNING
NON-PRODUCTIVE
RECUMBENT
BARKING
NOCTURNAL
PRODUCTIVE
BLOODY
CHRONIC BRONCHITIS
VIRAL, ILD,TUMOR
SINUSITUS, CHF,REFLUX
CROUP,LARYNGEAL
ASTHMA, CHF
INFECTIOUS
TUMOR,CHF
THE PNEA’S
 DYSPNEA – SOB :






ACUTE – (PULMONARY EMBOLISM, PNTX, ASTHMA)
CHRONIC – (COPD, CHF, ILD)
TACHYPNEA – RR>20 BR/MIN
BRADYPNEA - RR< 8 BR/MIN (DRUGS, AGONAL)
PND - PAROXYSMAL NOCTURNAL DYSPNEA SUDDEN
ONSET OF SOB DURING SLEEP (CHF)
ORTHOPNEA – SOB LYING FLAT (CHF)
PLATYPNEA – SOB SITTING UP AND BETTER LYING FLAT
(R TO L SHUNT)
TREPOPNEA – SHORTNESS OF BREATH IN ONE LATERAL
DECUBITUS POSITION WHICH IS IMPROVED BY TURNING
ON THE OPPOSITE SIDE
DYSPNEA
 MY CHEST FEELS TIGHT
 I CANNOT TAKE A DEEP BREATH
 I FEEL LIKE I HAVE A PILLOW OVER MY
MOUTH
 I AM SMOTHERING
THE NUMEROUS ETIOLOGIES
OF CHEST PAIN
 PLEURITIC – PARIETAL PLEURA – SHARP






STABBING – INSPIRATION
ESOPHAGEAL – REFLUX
CARDIAC – MYOCARDIAL INFARCTION
GALL BLADDER – CHOLECYSTITIS
CHEST WALL – COSTOCHONDRITIS
GREAT VESSELS – DISSECTION
PULMONARY - PNEUMOTHORAX
SPUTUM - WHAT ARE ITS
CHARACTERISTICS ?
YELLOW – GREEN (PNEUMONIA, BRONCHIECSTAIS)
RUSTY (PNEUMOCCOAL PNEUMONIA)
ANCHOVY PASTE (AMEBIASIS)
PINK – BLOOD TINGED (EPISTAXIS, BRONCHITIS)
FROTHY (CHF)
BLOODY (MALIGNANCY, BRONCHIECSTASIS,
PULMONARY RENAL SYNDROME)
 SMELL – FOUL? (ANAEROBIC LUNG ABCESS)
 SANDLIKE (BRONCHOLITHIASIS)
 BLACK – COAL DUST INHALATION






HEMOPTYSIS - REQUIRES
CAREFUL QUESTIONING
 THIS SYMPTOM USUALLY DENOTES A
SERIOUS ILLNESS. TB, TUMOR,
BRONCHIECSTASIS, PE, CARDIAC
DISEASE
 THE PATIENT SHOULD BE QUESTIONED
CAREFULLY REGARDING HOW MUCH,
FREQUENCY WEIGHT LOSS ETC.
CLUES TO DIFFERENTIATING
HEMOPTYSIS FROM HEMATEMESIS
HEMOPTYSIS
HEMATEMESIS
COUGH
FROTHY
COLOR- BRIGHT RED
PUS
DYSPNEA
CARDIAC DISEASE
NAUSEA – VOMITING
NOT FROTHY
COFFEE GROUNDS
FOOD
NAUSEA
GI DISEASE
THE PULMONARY
EXAMINATION
SIGNS
WHAT SHOULD WE KNOW ABOUT THE
EXAMINATION OF THE CHEST?
 HISTORY
 SYMPTOMS
 LANDMARKS
 PERTINENT VOCABULARY
 SIGNS
 HOW TO PERFORM AN EXAM
 HOW TO FORMULATE A DIFFERENTIAL DIAGNOSIS
 HOW TO PRESENT THE INFORMATION
TOPOGRAPHY OF THE CHEST
TOPOGRAPHY OF THE BACK
The Chest
 Inspection
 Palpation
 Percussion
 Auscultation
Inspection of the chest
Important:
- SHAPE
- MOVEMENT
of the thorax
- VISIBLE PULSATIONS!
SHAPE of the chest:
Deformities: - kyphosis
- scoliosis
- depressed sternum (pectus excavatum)
- bulges in left parasternal area
(congenital malformation)
e.g. VSD
Chest wall
Pectus carinatum
Pectus excavatum
Pectus Excavatum
Inspection









Shape
Scars
Lesions
Resp rate
Resp depth
Mode of breathing
Abnormal inspiratory movements
Abnormal expiratory movements
Asymmetry of movement
Nicotine staining
2 liters of O2
BARREL CHEST
Barrel Chest
AP Diameter = Transverse
Diameter
PALPATION
 FEELING WITH THE HAND – FINGERTIPS
 TEXTURES
 DIMENSIONS
 CONSISTENCY
 TEMPERATURE
Palpation
 Chest expansion
 Tactile vocal fremitus
Chest Expansion
Chest Expansion
Chest Expansion
Trachea exam
Percussion
 Illustrate resonance
 Compare both sides
 Map out abnormal area
METHODS OF PERCUSSION
DIRECT
INDIRECT
DISEASE A MONTH 41;643-692:1995
METHODS OF PERCUSSION
METHODS OF PERCUSSION
Percussion
Impaired(dull)resonance obtained –
 Aerated lung tissue is separated from the
chest wall e.g. fluid, pleural thickening
 Lung tissue is airless e.g. consolidation,
collapse, fibrosis
“stony dullness”- pleural effusion
Hyperresonance - pneumothorax
Percussion technique
 Place left hand on chest wall, palm
downwards with fingers separated
 2nd phalanx over area of intercostal space
 Right middle finger strikes the 2nd phalanx
producing hammer effect
 Entire movement comes from wrist
PERCUSSION SOUNDS
 TYMPANY – HEARD OVER THE ABDOMEN
 RESONANCE – HEARD OVER NORMAL
LUNG
 DULLNESS – HEARD OVER LIVER OR
THIGH
Auscultation
 Breath sounds
 Added sounds
 Vocal sounds (vocal resonance)
AUSCULTATORY PERCUSSION
METHOD
THE STETHOSCOPE IS PLACED OVER
THE POSTERIOR CHEST WALL, THE
CLINICIAN THEN TAPS LIGHTLY OVER
THE MANUBRIUM, EQUIVALENT SOUNDS
SHOULD BE HEARD OVER
CORRESPONDING AREAS OF THE LUNG.
ASYMETRY SUGGESTS DISEASE.
AUSCULTATORY PERCUSSION
MANGIONE PHYSICAL DIAGNOSIS SECRETS 2000
Auscultation of the front
Auscultation of the back
Breath Sounds
 Vesicular - normal
Diminished - localised or diffuse
 Bronchial - consolidation
FREMITUS =VIBRATION
TACTILE
VOCAL
BRONCHOPHONY
PECTORILOQUY
EGOPHONY
E>A
TACTILE FREMITUS
 A THRILL OR VIBRATION WHICH IS FELT
ON THE CLINICIANS HAND WHILE
RESTING IT ON THE PATIENTS CHEST
WALL AT T HE SAME TIME THE PATIENT
SPEAKS. 99 – 1-2-3
 SYMETRY MAY BE SEEN IN NORMALS
 ASYMETRY – IS ABNORMAL
TACTILE FREMITUS
INCREASED
 PNEUMONIA
DECREASED
 PNEUMOTHORAX
 PLEURAL EFFUSION
 COPD
 FAT
VOCAL FREMITUS
 THE PATIENTS VOICE IS HEARD
THROUGH A STETHOSCOPE PLACED ON
THE PATIENTS CHEST – NORMALLY THE
SOUNDS ARE INDISTINCT
 ABNORMALITIES – BRONCHOPHONY,
PECTORILOQUY, EGOPHONY
 CONSOLIDATION
VOCAL FREMITUS
 BRONCHOPHONY – SOUND OF THE BRONCHI – SOUND MUCH
LOUDER THAN NORMAL - WORDS INDISTINCT
 PECTORILOQUY – VOICE OF THE CHEST – WHISPER –
WORDS INDISTINCT
 EGOPHONY – VOICE OF THE GOAT – BLEATING - E – A
CHANGES – COMPARE SIDE TO SIDE
 REMEMBER - ALL SUGGEST CONSOLIDATION OF THE LUNG
THORACIC EXPANSION
 ASYMETRY IN EXPANSION OF THE THORAX CAN
BE DETECTED DURING INSPECTION OF THE
CHEST
 DURING PROMPTED INHALATION OBSERVE THE
MOVEMENT OF THE THORAX
 PLEURAL EFFUSION, PNEUMOTHORAX
CYANOSIS
 PERIPHERAL – HANDS, FEET – WARMING DECREASES
CYANOSIS – DECREASED CARDIAC OUTPUT
 CENTRAL- LIPS, TONGUE,SUBLINGUAL - RIGHT TO LEFT
SHUNTS
 PSEUDOCYANOSIS – BLUE PIGMENTS IN SKIN -
AMIODARONE
Central Cyanosis
 Results from pulmonary dysfunction, the
mucous membrane of conjunctiva and tongue
are bluish.
 If there was chronic hypoxemia and
secondary erythrocytosis, you can detect the
conjunctival and scleral vessels to be full,
tortuous and bluish.
Central Cyanosis
Corpulmonale
Sleep apnea syndrome
Clubbing
Hereditary
Interstitial Fibrosis
Tumor
Bronchiecstasis
Heart Disease
Endocarditis
Clubbing
Significance: Clubbing Observed In:
 Intrathoracic malignancy: Primary or
secondary (lung, pleural, mediastinal)
 Suppurative lung disease: (lung abscess,
bronchiectasis, empyema)
 Diffuse interstitial fibrosis: Alveolar capillary
block syndrome
 In association with other systemic disorders
CLUBBING
 PAINLESS – FINGERNAILS CURVED AND WARM
 ENLARGEMENT OF THE CONNECTIVE TISSUES
IN THE TERMINAL PHALANGES OF THE FINGERS
>TOES
CLUBBING
SCHAMROTH’S SIGN – LOSS OF THE SUBUNGUAL
ANGLE
CLIN CHEST MED 8:287-298,1987
CLUBBING
LOVIBOND’S ANGLE – THE ANGLE BETWEEN
THE BASE OF THE NAIL AND SURROUNDING
SKIN.
CLIN CHEST MED 8:287-298,1987
DO NOT FORGET THE TRACHEA
 TRACHEAL DEVIATION
 AUSCULTATE - STRIDOR
 TRACHEAL TUG (OLIVERS SIGN) – DOWNWARD
DISPLACEMENT OF THE CRICOID CARTILAGE
WITH VENTRICULAR CONTRACTION –
OBSERVED IN PATIENTS WITH AN AORTIC ARCH
ANEURYSM
 TRACHEAL TUG (CAMPBELL’S SIGN) –
DOWNWARD DISPACEMENT OF THE THYROID
CARTILAGE DURING INSPIRATION – SEEN IN
PATIENTS WITH COPD
ABNORMAL BREATHING PATTERNS
APNEA - CARDIAC ARREST
BIOTS – INCREASED INTRACRANIAL PRESSURE – DRUGSMEDULLA
CHEYNE STOKES – CONGESTIVE HEART FAILURE – DRUGS –
CEREBRAL
KUSSMAULS – METABOLIC ACIDOSIS
WHITE NOISE (NOISY
BREATHING)
 THIS NOISE CAN BE HEARD AT THE BEDSIDE
WITHOUT THE STETHOSCOPE
 LACKS A MUSICAL PITCH
 AIR TURBULENCE CAUSED BY NARROWED
AIRWAYS
 CHRONIC BRONCHITIS
LUNG SOUNDS
BREATH SOUNDS
ADVENTITIOUS
TRACHEAL
BRONCHIAL
VESICULAR
WHEEZE
RHONCHI
CRACKLE
PLEURAL RUB
STRIDOR
SQUEAK
BREATH SOUNDS
 VESICULAR – NORMAL BREATH SOUNDS - SITE OF PRODUCTION THE
ALVEOLI
 TRACHEAL – TUBULAR – LIKE BLOWING AIR THROUGH A HOLLOW
TUBE – PHYSIOLOGIC
 BRONCHIAL – TUBULAR -
ALWAYS PATHOLOGIC WHEN THEY
OCCUR OVER POSTERIOR OR LATERAL CHEST WALL
 BRONCHOVESICULAR – CHARACTERISTICS OF BOTH VESICULAR
AND TUBULAR – DO THEY EXIST?
 ADVENTITOUS – EXTRA SOUNDS
BREATH SOUNDS
TIMING
CHARACTERI
STIC
TRACHEAL
BRONCHIAL
BV
VESICULAR
INTENSITY
VERY LOUD
LOUD
MODERATE
LOW
I:E RATIO
1:1
1:3
1:1
3:1
Breath sounds

Vesicular breath sounds
 Vibrations of the vocal cords caused by
turbulent flow through the larynx
 Transmitted along trachea, bronchi to chest
wall
 Rustling quality
 Inspiration continuous with expiration
 Intensity increases during inspiration & fades
during first 1/3rd expiration
Diminished breath sounds
Conduction limited by
 Airflow limitation
e.g. diffusely – asthma, emphysema
localised – tumour, collapse
 Something separating chest wall from lung
e.g. effusion, fibrosis
Bronchial breathing
 “blowing” inspiratory & expiratory sounds
 Expiratory phase as long as inspiration
 Distinct pause between phases
 High-pitched e.g. consolidation
 Low-pitched e.g. fibrosis
Added sounds
 Rhonchi (wheeze)
 Crepitations (crackles)
 Pleural sounds
Rhonchi
 Due to passage of air through narrowed
bronchus e.g. bronchospasm, mucosal
oedema
 Musical quality
 High or low pitched
 Usually expiratory
 Expiration prolonged
Crepitations
 Inspiratory noises, usually 2nd half
 Non-musical
 Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
 Creaking noise
 Movement of visceral pleura over parietal
pleura
 Surfaces roughened by exudate
 2 separate phases at end inspiration and
early expiration
ADVENTITIOUS SOUNDS
 THESE ARE SOUNDS HEARD DURING
AUSCULTATION OTHER THAN BREATH
SOUNDS OR VOCAL RESONANCE
 NOMENCLATURE – HAS BEEN
CONFUSING
 CRACKLES – DISCONTINUOUS SOUNDS
 WHEEZES AND RHONCHI – CONTINUOUS
SOUNDS
ADVENTITIOUS LUNG SOUNDS (BRUITS
ETRANGERS – FOREIGN SOUNDS)
 WHEEZE – HIGH PITCHED
 RHONCHI – LOW PITCHED
 CRACKLE
RALES - HAIR VELCRO
(FINE – COARSE)
 PLEURAL RUBS – CREAKING LEATHER
 STRIDOR
 SQUEAK – HIGH PITCHED WHEEZE
HEARD AT THE END OF INSPIRATION
CRACKLES
EARLY AND MID INSPIRATORY
LATE INSPIRATORY
COARSE
FINE
LOW PITCHED
HIGH PITCHED
CLEAR WITH COUGHING
DO NOT CLEAR WITH
COUGHING
SCANTY
PROFUSE
GRAVITY IN DEPENDENT
GRAVITY DEPENDENT
TRANSMITTED TO THE MOUTH
POORLY TRANSMITTED TO THE
MOUTH
ASSOCIATED WITH
OBSTRUCTION
ASSOCIATED WITH
RESTRICTION
BRONCHITISBRONCHIECSTASIS
INTERSTITIAL FIBROSIS INTERSTITIAL EDEMA
SIGNIFICANCE OF LATE AND EARLY
CRACKLES
 EARLY – CENTRAL AIRWAYS (BRONCHITIS)
 LATE – PERIPHERAL AIRWAYS (FIBROSIS,EDEMA)
WHEEZING
 ASTHMA
 CONGESTIVE HEART
 BRONCHITIS
FAILURE
 COPD
 FORCED EXPIRATION IN
NORMAL SUBJECTS
 CYSTIC FIBROSIS
 VOCAL CORD
DYSFUNCTION
 FOREIGN BODY
ASPIRATION
 INFECTIONS – CROUP
LARYNGITIS
NOT ALL THAT WHEEZES IS ASTHMA
COPD
PINK PUFFERS
BLUE BLOATERS
DAHL’S SIGN
NICOTINE STAINS
SMOKERS FACE
THORAX 38:595-600, 1983
BLUE BLOATER
PURSED – LIPS BREATHING
 COPD – DECREASES DYSPNEA
 DECREASES RR
 INCREASES TIDAL VOLUME
 DECREASES WORK OF BREATHING
CHEST 101:75-78, 1992
HOOVERS SIGN
 COPD
 IN COPD THE DIAPHRAGM MAY BE
FLATTENED, DURING THE INSPIRATORY
PHASE OF A BREATH THE RIBS ARE
PULLED INWARD AND MEDIALLY RATHER
THAN OUTWARD AND LATERALLY
RESPIRATORY ALTERNANS
 NORMALLY BOTH CHEST AND ABDOMEN
RISE DURING INSPIRATION
 PARADOXICAL RESPIRATION IMPLIES
THAT DURING INSPIRATION THE CHEST
RISES AND THE ABDOMEN COLLAPSES
 IMPENDING MUSCLE FATIGUE
PUTTING IT ALL TOGETHER
 PNEUMONIA
 PNEUMOTHORAX
 PLEURAL EFFUSION
 ASTHMA
PNEUMONIA
PNEUMONIA
INSPECTION – SPLINTING
PALPATION – INCREASED FREMITUS
PERCUSSION – DULL
AUSCULTATION – BRONCHIAL BREATH
SOUNDS, CRACKLES, EGOPHONY,
PECTORILOQUY, RHONCHI
ENDOBRONCHIAL OBSTRUCTION
MAY MASK THE USUAL PHYSICAL
FINDINGS OF PNEUMONIA
Consolidation Chest xray
PLEURAL EFFUSION
PLEURAL EFFUSION
INSPECTION – LAG AFFECTED SIDE
PALPATION – ABSENT FREMITUS
PERCUSSION – FLAT, DULL
AUSCULTATION – ABSENT OVER EFFUSION,
BRONCHIAL IMMEDIATELY ABOVE
EFFUSION, RUB OCCASIONALLY
PNEUMOTHORAX
PNEUMOTHORAX
INSPECTION – LAG AFFECTED SIDE
PALPATION – ABSENT FREMITUS
PERCUSSION – TYMPANIC
AUSCULTATION – ABSENT BREATH
SOUNDS
PNEUMOTHORAX
PNEUMOTHORAX
Interpretation of findings
Pleural effusion
 reduced tactile vocal fremitus
 reduced chest expansion
 stony dull
 reduced air entry
 no added sounds
 reduced vocal resonance
Consolidation
 increased tactile vocal
fremitus
 reduced expansion
 dull percussion
 bronchial breathing
 coarse creps
 increased vocal resonance
 whispering pectoriloquy
Pleural effusion
Pleural Effusion
Interpretation of findings
Pneumothorax
 deviated trachea
 reduced tactile vocal
fremitus
 hyper-resonance
 reduced air entry
 reduced vocal
resonance
Collapse
 deviated trachea
 reduced tactile vocal
fremitus
 dull percussion
 reduced air entry
 +/- creps
pneumothorax
Symptoms of Cardiac disorders:
1. Symptoms due to lung congestion:
 Dyspnea.
 Acute pulmonary edema.
 Cough, hemoptysis.
 Recurrent chest infections.
2. Symptoms due to lung congestion:
 Pain in the right hypochondrium.
 Dyspepsia.
 Swelling of lower limb.
 Swelling of the abdomen.
 Oliguria.
3. Symptoms due to low cardiac output:
(tissue hypoxia →brain, muscles, kidneys)
 Exertional fatigue.
 Blurring of vision.
 Dizziness / Syncope.
 Oliguria, Angina.
4. Chest pain:
Of Cardiac Origin:
Ischemia, pericarditis, Dissecting aorta, Aortic Aneurysm.
1.
2.





Other Causes:
Chest wall
Neurological
Mediastinum
Diaphragm
Abdominal. ( esophagus, stomach, gall bladder,
pancreas).
Analysis:
1. Site & radiation.
2. Provocation & relief.
3. Duration.
4. Character.
5. Associated features.
5. Symptoms due to changes in rate,
Rhythm, or force → palpitation.
( time, mode of onset & offset, relation to
exertion, duration, irregularity).
6. Symptoms due to pressure on
surrounding structures.
( esophagus, bronchi , nerves, spine)
General Examination
General appearance.
Vital signs: pulse, temp. Blood pressure,
respiration.
Hands: (cold, warm, clubbing, cyanosis, sweating)
Eyes
Neck:
1.
2.
3.
4.
5.
I.
II.
III.
IV.
Neck veins.
Pulsations (arterial vs. venous).
Carotid arteries.
Trachea, thyroid gland.
6. Lower Limbs ( edema, pulsations).
7. Abdomen.
Local Examination
1. Combined Inspection and palpation:
1. Shape.
2. Cardiac impulses (apex beat, parasternal
3.
4.
5.
6.
7.
8.
pulsations, epigastric, to the right of
sternum, suprasternal notch, 2nd left space)
Thrills.
Palpable heart sounds.
Position of the mediastinum
Tactile vocal fremitus
Chest movements
Local tenderness,pulsations,wheezes.
Apex beat
2. Percussion
 Types of percussion notes
 Apices of the lungs
 Anterior chest wall
 Lateral chest wall
 Posterior chest wall
 Cardiac and hepatic dullness
3. Auscultation:
Apex, lower end of sternum (tricuspid area),
aortic area and pulmonary area .
 Murmurs:
1. Timing
2. Character
3. Point of maximum intensity and propagation
4. Relation to respiration
5. Intensity
6. ± Thrill.
 Breath sounds.
 Adventitious sounds.
 Vocal resonance .