this is about physical diagnostic

1. 04/16/2025 Physical diagnosis 1
Dire Dawa University CMHS
Physical diagnosis
For 2nd
year anesthesia students
By Dr. Fikremariam A. MD

2. Objectives
• Enable you to describe the chest wall anatomy and
identify the key areas for RS and CVS examination.
• Enable you perform basic techniques of respiratory
system and CVS examination
04/16/2025 Physical diagnosis 2

3. 04/16/2025 Physical diagnosis 3
Medicine is both science and art!

4. The respiratory System examination
 Positioning the patient
 If he or she is not acutely ill, the examination is
easiest to perform with the patient sitting over the
edge of the bed or even on a chair.
 The patient should be undressed to the waist.

5. Respiratory System examination Con…
 The cardinal steps of chest examination are
 Inspection,
 Palpation,
 Percussion and
 Auscultation

6. Inspection
General Assessment
Physique
Cyanosis/Paler
 Clubbing
 Flaring of ala nasi
 Breathing patterns
 Use of accessory muscles
Respiratory rate and rhythm
 Normal=14-16/min
 Tachypnea > 20/min
 Chest indrowing (retractions)

7. Inspection of the Chest
 Appearance of the chest/Shape
 Bilaterally symmetrical and an elliptical in cross section
 Shape of the chest
 Kyphosis
 Scoliosis
 Flattening
 Over inflation
 Movement of the chest
 Symmetry
 Observe the chest for –rate and rhythm
-chest expansion

8. Cyanosis
 Look central and peripheral cyanosis:- over tongue,
lips, other mucous membranes & fingers.
 Excessive amount of reduced hemoglobin in capillary
blood.

9. Clubbing of fingers
 Clubbing of fingers is the bulbous
enlargement (like drum stick) of soft parts of
the terminal phalanges due to
an increase in the vascularity of the distal fingers
and consequently an increased sponginess of the
nail beds
with over curving of the nails both transversely
and longitudinally.

10. Grades of clubbing
 Grade I: Spongy, boggy feeling on pressing the nail
bed – (early clubbing)
 Grade II: loss of angle at the nail bed >160 i.e. 180 or
more .
 Grade III: widening of the distal part of the phalanx,
spooning nail (late clubbing)=drum stick

11. • Flaring of ala nasi
 Flaring of ala nasi is the spreading out of the nostrils
during expiration in children due to respiratory
distress.
• Breathing patterns (rate, rhythm, and depth)
 The rate, rhythm, and depth of breathing should be
noted carefully.
a. Rate:- see under vital sign, RR
b. Rhythm of breathing (regular, or irregular)

12. • Use of accessory muscles
 Is there use of the neck muscles such as sternomastiod,
scaleni & trapezius muscles for respiration?
 The normal muscles of respiration are the diaphragm , the
intercostal muscles and abdominal muscles
 Diaphragm descends on inspiration & cause outward
abdominal movement.
 Intercostal muscles cause chest expansion on inspiration.
 In labored breathing (i.e. in respiratory distress) neck
muscles (accessory muscles of respiration) are recruited to lift
the chest

13. • Shape of the chest wall
 Inspect the chest wall for deformities (first the
front of the chest and then the back).
Normal chest wall – is symmetrical and In the infant
or young child, almost round
 The transverse diameter increases with age, thus
elliptical in cross section
Abnormalities (deformities) of chest wall includes:
 Barrel chest – a persistently round (increased
antero-posterior) diameter of chest wall.

14.  Pigeon chest - is chest wall with prominent sternum
& flat chest (pectus carinatum), is sequel of chronic
respiratory disease in childhood.
 Funnel chest - is chest wall with local sternum
depression at lower end (pectus excavatum).
 Kyphosis – is forward bending of spines
 Scoliosis –is lateral curvature of spines
 Harrison's groove–is a horizontal depression along
the lower border of the chest that corresponds with
the costal insertions of the diaphragm.
 Rachitic rosaries–is a palpable or visible
costochondral beading

15. • Symmetry of chest wall movement
 Inspect movements of the two sides & both upper
& lower parts of the chest.
 Inspiration normally results in expansion of the
chest wall and depression of the diaphragm.
Normal chest moves symmetrically & equal on both
sides.
 Impairment of respiratory movement on one or
both sides or unilateral lag (or delay) in that
movement

16. • Chest indrowing (retractions)
 Retraction (indrowing) of the intercostal spaces,
subcostal, suprasternal, and supraclavicular fossae
during
 Inspiration in the present of airway obstruction &
non-compliant lung

17. Palpation
 Tenderness
 Mass or swelling
 Position of trachea
 Tactile fremitus
 Chest expansion

18. • Tenderness
 Palpate the chest wall where patient complains of
pain.
 Intercostal tenderness may be due to inflamed
pleura (e.g tuberculosis).
Causes of chest pain & tenderness:
 Recent injury of the chest or inflammatory conditions
 Intercostal muscular pain
 Rib fracture
 malignant deposits in the ribs
 Herpes zoster before appearance of eruption
 Pleurisy (inflammation of pleura

19. • Position of trachea
 Position of trachea indicates the position of upper
mediastinum.
 Normally on midline, may slightly deviates to the right.
 Abnormal tracheal deviations
 Deviation to same side of the cause (pulled to one side), as in
 Lung collapse
 Lung fibrosis
 Deviation to the opposite side of the cause (pushed to
opposite side) by
 Pleural effusion
 Pneumothorax

20. • Tactile fremitus (TF)
 TF refers to palpable vibrations transmitted
through the broncho-pulmonary tree from the
larynx to the surface of the chest wall when the
patient speaks.
 1. Ask the patient to say the following several
times in a normal voice:
 Ninety nine for English speakers
 ‘arba arat’ for Amharic speakers

21.  Increased TF in
 Lung consolidation
 Lung fibrosis
 Decreased to absent TF when transmission of
vibrations from the larynx to the surface of the chest
is impeded by:
 Obstructed bronchus
 Chronic obstructive pulmonary disease (COPD)
 Separation of the lung from chest wall by:
 Pleural air e.g. Pneumothorax
 Pleural fluid e.g. pleural effusion, hemothorax
 Pleura thickening

22. • Chest expansion
 Place the fingertips 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 anterior or posterior side
of chest), then the patient is asked to breath deeply.
 Posteriorly, at the level of and parallel to the 10th ribs.
 If one thumb remains closer to the mid line – indicates
that there is diminished expansion of the chest on that
side.
 Causes:– see under symmetry of chest movement.

23. Cont..

24. Percussion
 Resonance
 Hyper resonance
 Dull
 Stony (flat) dullness
 Diaphragmatic excursion

25. Cont..
Posterior
Anterior

26. Proper Technique
• Hyperextend the middle finger of one hand and place
the distal interphalangeal joint firmly against the
patient's chest.
• With the end (not the pad) of the opposite middle
finger, use a quick flick of the wrist to strike first
finger.
 Posterior Chest
1. Tell the patient to cross his/her hands in front of their
chest grasping the opposite shoulders so as to pull the
scapulae laterally.

27.  2. Percuss from side to side and top to bottom using
the pattern shown in the illustration. Omit the areas
covered by the scapulae.
 3. Compare one side to the other looking for
asymmetry.
 4. Note the location and quality of the percussion
sounds you hear.
 5. Find the level of the diaphragmatic dullness on
both sides

28.  The normal percussion note of underlying
air-containing normal lung field is resonance.
 Abnormal percussion notes are:
 Hyper resonance – occurs in emphysema (hyper inflated
lung), or Pneumothorax (when pleural cavity is filled with
air)
 Dull as in lung consolidation, lung fibrosis, lung collapse,
pleural thickening.
 Stony (flat) dullness – is due to fluid or blood in the
pleural cavity as in pleural effusion & hemothorax

29. Diaphragmatic excursion
• Percuss along the scapular line on one side until the
level of the diaphragmatic dullness.
• Ask the patient to inspire deeply and hold his breath
in.
• Proceed to percuss down from the marked point –to
determine the diaphragmatic excursion in deep
inspiration.
• Repeat the procedure on the opposite side.
• Measure the distance between the upper & lower
points in cm on each side.
• Excursion is normally 3–5cm bilaterally
(symmetrically)

30. Auscultation
 Air entry
 Breath sounds
 Added (adventitious) sounds

31.  Ask the patient to breathe (i.e. to let the air into the
lungs & let it out again) while auscultating the chest.
 Sequential examination proceeds from one side of
the chest to the other
 Comparing breath sounds in anatomically similar
areas of both sides of posterior, lateral & anterior
chest using the pattern shown in the illustration
above.
 Omit the areas covered by the scapulae.

32. • Air entry
 Normal
 Decreased / absent
 Increased
 Normal breath sounds are
Vesicular breath sound- Lung tissue;
 It is rather quite low-pitched rustling sound without distinct pause (gap) between the end of
the inspiration and the beginning of expiration.
 Inspiration phase greater than expiration
Bronchial breath sound- Trachea
 It is a harsh, tubular, sound, 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
Vesiculo-broncheal breath sound- between the scapula over
main bronchi

33. Normal air entry - in normal lung
Decreased to absent air entry in
 Pleural effusion
 Lung collapse
 Pneumothorax
 Hemothorax
 Severe asthma
 Major bronchial obstruction
Increased air entry in
 Lung consolidation
 Lung fibrosis

34.  Bronchial breath sound (BBS) is heard over the
lung fields in
 Lung consolidation
 Lung fibrosis
 Over top of pleural effusion
 Amphoric breath sounds
 It is a sound heard like that made by blowing over
the mouth of a narrow necked glass e.g. bottle.
 It is heard over:
 Cavitary lesions
 Top of pleural effusion

35.  Decreased or absent breath sounds can occur in:
 Any condition that causes the deposition of foreign
matter (air, fluid, blood) in the pleural space such as
pneumothorax, pleural effusion, hemothorax
 Emphysema,
 Endobronchial obstruction

36. Bronchophony
• 1. Ask the patient to say "ninety-nine", or “arba arat”,
several times in a normal voice.
• 2. Auscultate several symmetrical areas over each
lung.
• 3. The sounds you hear should be muffled and
indistinct.
• But if Louder, clearer sounds are called
bronchophony.

37. Whispered Pectoriloquy
• 1. Ask the patient to whisper "ninety-nine", or
“arba arat”, several times.
• 2. Auscultate several symmetrical areas over
each lung.
• 3. You should hear only faint sounds or
nothing at all.
• If you hear the sounds clearly this is referred
to as
• whispered pectoriloquy.

38. Egophony
• 1. Ask the patient to say "ee" continuously.
• 2. Auscultate several symmetrical areas over
each lung.
• 3. You should hear a muffled "ee" sound. If
you hear an "ay" sound this is referred to as
"E A" or
→
• Egophony.

39. Added (adventitious) sounds
 Crackles / rales
 Wheezes/ronchi
 Pleural friction rub
 Stridor

40.  Rales / crepitations / crackles: (rales are old
terms)
 Rales/crepitations are short, discrete, interrupted
crackling sound that are heard during inspiration.
 Fine crepitation is heard in
 pulmonary edema
fibrosing alveolitis
 Coarse crepitation is heard in
 bronchiectasis
 bronchogenic pneumonia

41.  Rhonchi
 Rhonchi are continuous sounds produced by the
movement of air in the presence of free fliud in the
airway lumen, the tracheobroncheal tree.
 Wheezes: are often audible at the mouth as well as
through the chest wall.
 Wheezes, which are generally more prominent
during expiration than inspiration,
 Reflect the oscillation of airway walls that occurs
when there is airflow limitation,

42.  Wheeze is heard in:
 Bronchial asthma
 Bronchitis
 Laryngeal spasm
 Tracheal fibrosis
 Congestive heart failure (cardiac asthma

43. Pleural friction rub
 Pleural friction rub is heard as creaking noise
(emitted by compression of new leather).
 It indicates inflamed pleural surfaces rubbing
against each other, often during both inspiratory
and expiratory phases of the respiratory cycle.
e.g. inflammatory conditions of the pleura (pleurisy) from
adjacent pneumonia or Tb, pulmonary infarction

44. Stridor
 Stridor is a wheeze that is entirely or predominantly
inspiratory i.e. heard on inspiration and
 arises from a narrowed airway out side the thorax
(usually trachea) that tends to close on inspiration
This condition can be caused by a croup-like illness,
epiglottitis, anatomical defect, mass lesion, foreign
body, or external obstruction.

45. Comparison of the chest signs in common respiratory disorders
Disorder Mediastinal
displaceme
nt
Chest wall
movement
Percussion
note
Breath
sounds
Added
sounds
Consolidation None Reduced
over affected
area
Dull Bronchial Crackles
Collapse Ipsilateral
shift
Decreased
over affected
area
Dull Absent or
reduced
Absent
Pleural
effusion
Heart
displaced to
opposite side
(trachea
displaced
only if
massive)
Reduced
over affected
area
Stony dull Absent over
fluid; may be
bronchial at
upper border
Absent;
pleural rub
may be found
above
effusion

46. Pneumothorax Tracheal
deviation to
opposite
side if
under
tension
Decreased
over affected
area
Resonant Absent or
greatly
reduced
Absent
Bronchial
asthma
None Decreased
symmetricall
y
Normal or
decreased
Normal or
reduced
Wheeze
Interstitial
pulmonary
fibrosis
None Decreased
symmetricall
y (minimal)
unaffected by
cough or
posture
Normal Fine, late or
pan-
inspiratory
crackles over
affected lobes

47. Summary of Respiratory system
• Inspection
• Palpation
• Percussion
• Auscultation
-Cyanosis and clubbing
-Rate, Rhythm, Depth of
breathing
-Symmetry and shape
-Use of accessory muscle,
retraction and nasal flaring
-Mass and tenderness
-Degree of chest expansion
-Tactile fremitus
-Position of trachea
-Percussion note of lung
field
-Diaphragmatic excursion
-Air entry
-Breath sounds
-Any added sounds

48. 04/16/2025 Physical diagnosis 48
EXAMINATION OF THE CARDIOVASCULAR
SYSTEM
Peripheral and precordial
examination

49. EXAMINATION OF THE ARTERIAL SYSTEM
1. Assessing the pulses
 Rate
 Rhythm
 Character
 Volume/Amplitude
2. Assessing the vessel wall
3. Auscultation
 Bruit

50. SITES OF PALPATION
• Peripheral arteries(radial, ulnar, popliteal, dorsalis pedis,
and posterior tibial)
• More central arteries(Carotid,Femoral and Brachial)

51. JUGULAR VENOUS PRESSURE (JVP)

52. JUGULAR VEINS

53. JUGULAR VENOUS EXAMINATION
• The patient is examined at the optimal degree of
trunk elevation for visualization of venous pulsations
• Relax neck muscles and turn the head slightly away from the
examiner
• Good tangential light (shining a beam of light
tangentially across the skin overlying the vein
exposes the pulsations of the internal jugular vein)
• Differentiate jugular venous pulsation from that of carotid
artery
• Estimation of the Central Venous Pressure (CVP)

54. CHARACTERISTICS OF JVP
• The top of the venous pulsation can be visible
• Height of column Increased by
 Deep expiration
 Cough
 Hepatojugular/abdominojugular reflux test:
 Valsalva manouever
 Supine position

55. CHARACTERISTICS OF JVP
• Height of column falls by deep inspiration
 Kussmaul’s sign: an increase rather than the normal
decrease in the CVP during inspiration
*Constrictive pericarditis
*Right ventricular infarction
• Not palpable
• Multiple waves
• Effect of Pressure: Can be obliterated with gentle
pressure at base of vein/clavicle

56. MEASURING CVP
• IJV (Internal Jugular Vein)is preferred because the EJV is valved
and not directly in line with the superior vena cava (SVC) and
right atrium (RA)
• CVP= JVP + 5 cm of H2o or blood
• JVP is measured as the vertical distance between the top of the
oscillating venous column and the level of the sternal angle
• The sternal angle is used as the reference point because the
center of the right atrium (the zero reference ) lies
approximately 5 cm below the sternal angle in the average
patient, regardless of body position
• A distance of >3 cm is considered abnormal

57. MEASURING CVP

58. 04/16/2025 Physical diagnosis 58

59. PATHOLOGIC CAUSES OF RAISED JVP
• Heart failure
• Pericardial effusion
• Constrictive pericarditis
• Superior vena cava obstruction

60. EXAMINATION OF THE PRECORDIUM

61. INSPECTION
• Activity
 Active
 Quite
• Deformity (e.g. Bulged precordium)
• Apical Impulse

62. PALPATION
1. Apical beat/Apical impulse localization
2. Point of Maximal Pulsation (PMI)
 The point where maximal pulsation is felt
 Usually located over the apical beat
3. Palpable heart sounds
4. Thrill
 Palpable murmur or bruit
 Use the palm of the hand
 Timing and location
5. Heave/Lift
 Forcefull elevation of the precordium
 Apical/parasternal

63. APICAL IMPULSE
• It is the lowest and outer most point of cardiac
pulsation
• Evaluation should begin with the patient in the
supine position at 30 degrees
• If the apical impulse is not palpable in this position
 Left latteral (left arm above the head)
 Sitting
• Best appreciated using finger tips
• The normal left ventricular apex impulse is located
 at or medial to the left midclavicular line in the fourth
or fifth intercostal space
 7-9 cm from midline

64. CHARACTERIZATION OF THE APICAL IMPULSE
1. Palpable or not
o Causes of abscent apical beat:
 Obesity
 Muscular
 Obscured by ribs
 COPD
 Pericardial effusion
 Weak cardiac muscle contraction

65. CHARACTERIZATION OF THE APICAL IMPULSE
2. Localization
o Causes of displaced apical impulse:
 Thoracic cage deformity
 Lung collapse/fibrosis
 Massive pleural effusion/Tension pneumothorax
 Intraabdominal mass/fluid collection
 Left ventricular (LV) cavity enlargement
 LV hypertrophy

66. AUSCULTATION
• Quite room
• Stethscope
 Bell: low pitched sound (S3,S4,diastolic murmur at
atrioventricular valves)
 Diaphragm: high pitched sounds (S1,S2,Clicks,opening
snaps,pericardial knocks,atrioventricular valve systolic
murmurs,semilunar valve murmurs)

67. STANDARD AUSCULTATORY POSITIONS
1. Supine: all
2. Supine and left latteral
 Apical diastolic murmur
 Apical S3
3. Sitting: all
4. Sitting and leaning forward
 Diastolic murmur at semilunar valves
 Pericardial friction rub

68. STANDARD AUSCULTATORY AREAS
1. Aortic area
 Right second intercostal space
2. Pulmonic area
 Left second intercostal space
3. Erbe’s point
 Left third intercostal space
4. Tricuspid area
 Left lower sterna boarder
5. Mitrtal area
 Apex of the heart

69. WHAT TO AUSCULTATE?
1. Heart sounds
2. Murmurs
3. Pericardial friction rub

70. HEART SOUNDS
1. S1: atrioventricular (AV) valve closure
 Comprises mitral (M1) and tricuspid (T1) valve closure
2. S2: closure of semilunar valves
 Comprises aortic (A2) and pulmonic (P2) valve closure

71. HEART SOUNDS
3. Diastolic sounds
 Third heart sound (S3):
 Is a low-pitched sound produced in the ventricle
after A2 at the termination of rapid filling
 It is also called protodiastolic or ventricular gallop
 Indicates impairment of ventricular function, AV
valve regurgitation, or other conditions that
increase the rate or volume of ventricular filling
 Normal in children, adolescents, young adults and
during pregnancy
 An S3 that is earlier and higher-pitched than normal
(pericardial knock) often occurs in patients with
constrictive pericarditis

72. HEART SOUNDS
3. Diastolic sounds (ctd)
 Fourth heart sound (S4)
 Also called presystolic or atrial gallop
 Is a low-pitched, presystolic sound produced during
the atrial filling phase of ventricular diastole
 Is as a result of diminished ventricular compliance
leading to increased resistance to ventricular filling
 Frequently present in patients with systemic
hypertension, AS, HCM, IHD, right ventricular
hypertrophy and acute MR
 With out structural heart disease: delayed AV
conduction or elderly

73. HEART SOUNDS
3. Diastolic sounds (ctd)
 Opening snap (OS)
 A brief, high-pitched, early diastolic sound
 Usually due to stenosis of an AV valve, most often
the mitral valve
4. Systolic sounds
 Ejection sound (Ejection click)
 Sharp, high-pitched sound occurring in early systole
and closely following the first heart sound
 It occurs in the presence of semilunar valve stenosis
and in conditions associated with dilation of the
aorta or pulmonary artery

74. HEART SOUNDS

75. CARDIAC MURMURS
• Result from audible vibrations caused by increased
turbulence
• Not all murmurs are indicative of valvular or
structural heart disease
• Characterization of a murmur:
1. Intensity (Loudness)
2. Configuration
3. Timing and duration
4. Location
5. Radiation
6. Quality
7. Response to various physiologic maneuvers

76. GRADING INTENSITY OF MURMUR
• Grade I: faint that it can be heard only with special
effort
• Grade II: Low intensity and heard immediately upon
placing the stethoscope on the chest
• Grade III: Moderately loud and no thrill
• Grade IV: Loud and has thrill
• Grade V: Very loud and heard with the stethoscope
partially off the chest
• Grade VI: Audible with the stethoscope removed from
contact with the chest wall by <= 1 cm

77. TIMING AND DURATION
• Systolic Murmurs
 Early
 Mid
 Late
 Holosystolic
• Diastolic Murmurs
 Early
 Mid
 Late
• Continuous Murmurs

78. PRINCIPAL CAUSES OF CARDIAC MURMURS

79. PRINCIPAL CAUSES OF CARDIAC MURMURS

80. PRINCIPAL CAUSES OF CARDIAC MURMURS

81. PRINCIPAL CAUSES OF CARDIAC MURMURS

82. PRINCIPAL CAUSES OF CARDIAC MURMURS

83. PRINCIPAL CAUSES OF CARDIAC MURMURS

84. PERICARDIAL FRICTION RUB
• Has three components
 Systolic
 Presystolic
 Early Diastolic
• Best appreciated with the patient upright and leaning
forward
• May be accentuated during expiration

85. Cardiovascular system
• Peripheral signs – Breathing pattern, Cyanosis, clubbing, edema, skin changes
• Arteries-BP (both arms & legs when indicated- supine& sitting)and Pulse (at all
accessible arteries- the rate, rhythm, volume, character)
• Veins-JVP, hepato-jugular reflux, kussmaul’s sign, any vein pathology(varices,
phlebitis…)
• Precordium
-Inspection
-Palpation
-Percussion
-Auscultation
-Deformity or bulging
-Active or quiet precordium
-Apical beat (location, distance)
-Heart sounds
-Any added
-PMI & its character
-Palpable heart sounds
-Heave
-Thrill
-Cardiac
outline

86. REFERANCES
• Harrison’s Principles of Internal Medicine, 20th
Edition
• Bates physical diagnosis