1. RS Physical Examination
Hadeel Khadawardi, teaching assistant at Internal Medicine Department, Faculty of Medicine, Umm Al-Qura University

2. Introduction General Approach Vital Signs Position Coughing/ Sputum
Strider/ Wheezing
Vital Signs
Position 45
sitting over the edge of bed or
on chair

3. RS Exam Peripheral Exam Chest Exam Hand Inspection Wrist Palpation
Face
Neck ?
Inspection
Palpation
Percussion
Auscultation

4. Hand
Nail Fingers Dorsum

5. Hand Nail Clubbing / HPO Peripheral Cyanosis
What are the causes of clubbing?
What is the chronic respiratory disease that dose not cause clubbing?

6. Hand
Fingers
Nicotine Stain

7. Hand
Dorsum
Muscle Wasting

8. Wrist Flapping tremor (Asterixis)
What are the causes of flapping tremor?
What is fine tremor?

9. Face
Eyes Nose Mouth Sinuses

10. Face Eye Pallor Horner’s Syndrome Meiosis Partial ptosis
Loss of sweating

11. Face
Nose
Deviated nasal septum
Polyps
Enlarged turbinate

12. Face Mouth Peripheral cyanosis Central cyanosis Signs of URTI
Infected teeth

13. Face
Sinuses

14. JVP
Neck ?

15. Chest Exam
Expose the chest properly to the waist including the axilla.
Exam the anterior and posterior chest.
Inspection, Palpation, Percussion, Auscultation
Always compare the right and left sides.

16. Surface Anatomy of the Lung

17. Ant. Chest

18. Ant. Chest Inspection (5S) Symmetrical chest movement (decrease)
Shape of the chest
Scar
Prominent veins in SVC obstruction
Subcutaneous emphysema

19. Ant. Chest What is Paradoxical breathing?
What are the causes of unilateral decrease chest movement?
What are the causes of bilateral decrease chest movement?

20. Ant. Chest Palpation Trachea Centralized OR displaced.
Normally, trachea is slightly displaced to the right side.
What is Tracheal Tug?
What are the causes of trachea displacement toward the side of lung lesion?
What are the causes of trachea displacement away from the side of lung lesion?

21. Thumbs move symmetrically apart for 3-4 cm
Ant. Chest
Palpation
Chest Expansion
Apical
Supra mammary
Infra mammary
Inspiration
Thumbs move symmetrically apart for 3-4 cm

22. Ant. Chest Palpation Apex beat Site Size Character
What are the causes of apex beat displacement toward the side of lung lesion?
What are the causes of apex beat displacement away from the side of lung lesion?
What is the lung disease causes of impalpable apex beat ?

23. Ant. Chest Palpation Tactile Vocal Fremitus Sites
Use ulnar side of the hand.
Ask the patient to say 99 in Eng. Or 44 in Arab.
Move in zigzag and compare both sides.
Comment as: equal, decrease, or increase TVF.
Sites
Supra clavicle
Infra clavicle
Supra mammary
Infra mammary
Upper axillary
Lower axillary

24. Ant. Chest Palpation Tactile Vocal Fremitus
What are the causes of decrease TVF?
What are the causes of increase TVF?

25. Ant. Chest
Palpation
Ribs
For tenderness

26. Ant. Chest Palpation Trachea Chest Expansion Apex beat
Tactile Vocal Fremitus
Ribs

27. Ant. Chest Percussion Sites Supra clavicle clavicle Infra clavicle
Supra mammary
Infra mammary
Upper axillary
Lower axillary
Move in zigzag and compare both sides

28. Ant. Chest Percussion Comment as: Resonant ………….. Hyper resonant ……..
Dullness ………….....
Stony Dullness ……...
Normal
Pneumothorax
Pneumonia
Pleural effusion

29. Ant. Chest Auscultation Sites Supra clavicle = Apical Infra clavicle
Supra mammary
Infra mammary
Upper axillary
Lower axillary
Move in zigzag and compare both sides

30. Ant. Chest Auscultation Comment on:
Breath sounds, equal, decrease, or absent
Quality of breath sounds, vesicular vs. bronchial
Added sounds, wheezing, crackles
Vocal resonance, equal, decrease, or increase
Ask the patient to say 99 in Eng. Or 44 in Arab

31. Ant. Chest Auscultation Quality of breath sounds
No gap
Insp > Exp
Quality of breath sounds
Vesicular breathing …Normal
Bronchial breathing …Consolidation
Gap
Insp = Exp

32. Ant. Chest Auscultation Added breath sounds Wheezing… Asthma Crackles…
Fine………
Medium…
Coarse……
Asthma
Lung fibrosis
LVF, pneumonia
Bronchiectasis

33. Ant. Chest Auscultation Vocal Resonance
What are the causes of decrease vocal resonance?
What are the causes of increase vocal resonance?

34. Ant. Chest Auscultation What is Aegophony?
What is Whispering Pectoriloquy?
What is the indication of silent chest in asthmatic patient?

35. Post. Chest

36. Post. Chest
Ask the patient to sit at the edge of the bed and you face his/her back.
Ask the patient to make cross his/her arms on front chest to rotate the scapula anteriorly.

37. Post. Chest
Inspection
Shape of the chest
Scar

38. Thumbs move symmetrically apart for 3-4 cm
Post. Chest
Palpation
Chest Expansion
Basal
Thumbs move symmetrically apart for 3-4 cm

39. Post. Chest Palpation Tactile Vocal Fremitus Sites Supra scapular
Intra scapular
Infra scapular
basal
Upper axillary
Lower axillary
Move in zigzag and compare both sides

40. Post. Chest
Palpation
Chest Expansion
Tactile Vocal Fremitus

41. Post. Chest Percussion Sites Supra scapular Intra scapular
Infra scapular
basal
Upper axillary
Lower axillary
Move in zigzag and compare both sides

42. Post. Chest Percussion Comment as: Resonant ………….. Hyper resonant ……..
Dullness ………….....
Stony Dullness ……...
Normal
Pneumothorax
Pneumonia
Pleural effusion

43. Post. Chest Auscultation Sites Supra scapular Intra scapular
Infra scapular
basal
Upper axillary
Lower axillary
Move in zigzag and compare both sides

44. Post. Chest Auscultation Comment on:
Breath sounds, equal, decrease, or absent
Quality of breath sounds, vesicular vs. bronchial
Added sounds, wheezing, crackles
Vocal resonance, equal, decrease, or increase
Ask the patient to say 99 in Eng. Or 44 in Arab

45. Pemberton’s Sign

46. Optimize, Your Future is Going to be Better ….