Lecture 2 by Dr.Mohammed Hussien clinical pharmacy ( kafrelsheikh University)

1. Introduction to Physical
Assessment Skills
Dr/ Mohammed Hussien
Assistant Lecturer of Gastroenterology & Hepatology
Kafrelsheik University
Membership at American Collage of Gastroenterology (ACG)
Membership at Egyptian association for Research and training in
Hepatogastroentrology
2018

2. Head and Neck
Techniques
The structures of the head and neck (skull, scalp, face, neck, nose, ears, mouth and pharynx, and eyes) are evaluated
through inspection and palpation. Percussion and auscultation are rarely indicated. Visual acuity, hearing, and facial and
ophthalmic reflexes are tested when clinically indicated.
Inspection
Skull: Inspect the skull for size, shape, and evidence of trauma.
•
Hair: Inspect the hair for quantity, texture, and distribution.
•
Scalp: Inspect the scalp for lesions and scales.
•
Face: Inspect the face for expression, symmetry, movement, lesions, and edema.
•
Neck: Inspect the neck for symmetry, masses, and enlargement of the parotid and submaxillary glands and lymph
nodes

4. Lymph nodes are located in several regions of the head and neck.
External nose and nasal cavity: Inspect the external nose and nasal cavity for symmetry, inflammation, and lesions.
•
Sinuses: Transilluminate the maxillary sinuses by shining a bright light in the mouth. Normal maxillary sinuses appear as dull-
red crescent-shaped glowing areas under each eye. Transilluminate the frontal sinuses by placing a light source under the medial
aspect of each eyebrow. Normal frontal sinuses appear as glowing red areas above each eye. Fluid-filled sinuses (e.g., in
sinusitis) glow less.
External ear: Inspect the external ear for lesions, trauma, size, and contour.
•
Ear canal and tympanic membranes: Inspect the ear canal and tympanic membranes with the otoscope. Insert the otoscope by
tipping the patient’s head slightly to the opposite side and gently pulling the auricle up, back, and slightly outward (movement of
the auricle is painful in acute otitis externa). Inspect the canal for foreign bodies (e.g., insects, pieces of toys), discharge (note
color), and edema. Inspect the tympanic membrane for color, bulging, perforations, and air-fluid level. An air-fluid level is
associated with middle ear infections

5. Mouth: Use gloves or hold the paper-wrapped end of a partially unwrapped
tongue depressor while examining the oropharynx; use a penlight (or flashlight)
to illuminate the areas being inspected. Inspect the lips and mucosa for color,
ulcerations, hydration, and lesions. Inspect the teeth and gums for color,
bleeding, inflammation, caries, missing teeth, ulcerations, and lesions. Inspect
the tonsils and posterior palate for color, edema, ulcerations, exudates, and
lesions. Inspect the top, sides, and bottom of the tongue for color, symmetry,
ulcerations, and lesions. Note the odor of the breath (e.g., alcohol odor in
alcoholic intoxication, urinous odor in uremia, sweetish fruity odor in diabetes
mellitus with ketoacidosis, a musty odor [fetor hepaticus] in severe

7. Eyes

8. Palpation
Skull: Palpate the skull for lumps, bumps, and evidence of trauma.
Hair: Palpate the hair for texture (coarse, fine, dry, oily).
Thyroid gland: Palpate the thyroid gland for size, shape, symmetry, tenderness, and
nodules.
Lymph nodes: Palpate the lymph nodes for size, shape, mobility, and tenderness.
Sinuses: Palpate the frontal, ethmoid, and maxillary sinuses for tenderness
External ear: Palpate the external ear for nodules.
Auscultation

9. A commonly used but relatively inaccurate assessment of hearing is to test, one ear at a time, the ability of the patient
to hear a sequence of equally accented syllables (e.g., three-five-two-four) whispered from a distance of a couple of
feet. The Rinne test compares sensitivity with bone and air conduction .
Common medical terms
Acromegaly: A pituitary disorder characterized by a massive face with enlarged lower jaw, prominent nose
and eyebrows, and coarse facial features and large hands and feet
Arteriovenous (AV) nicking: An abnormality visualized on funduscopic examination and associated with
hypertension; at AV crossings the vein appears to stop abruptly on either side of the arteriole

10. Arteriovenous (AV) tapering: An abnormality visualized on funduscopic examination and associated
with hypertension; at AV crossings the vein appears to taper off on either side of the arteriole
Astigmatism: A condition characterized by unequal curvature of the cornea
Audiometry: A test used to determine hearing levels
Bell’s palsy: Unilateral paralysis of the facial nerve
Exophthalmos: Abnormal protrusion of the eyeball; associated with Graves’ disease

11. Fissured tongue: Increased tongue fissures; benign; sometimes associated with aging
Hirsutism: Increased hair growth in androgen-sensitive areas (e.g., beard or mustache areas); associated
with ovarian, adrenal, thyroid, and pituitary disorders and some medications
Hyperopia: Farsightedness
microaneurysm: An abnormality visualized on funduscopic examination; associated with diabetes; appears as a
tiny red spot in the macular area
Normocephalic, atraumatic: A physical examination finding meaning that the head is of normal size and shape
and no evidence of trauma is present
Periorbital edema: Puffiness of the upper and lower eyelids
Rinne test: A hearing test that compares air and bone conduction
Smooth red tongue: Finding associated with deficiencies of vitamin B12, niacin, and iron
Weber’s test: A hearing test that compares bone conduction in both ears
Xanthoma: Yellow, raised, well-circumscribed plaques found in the skin around the eyelids; associated with
hypercholesterolemia

12. Chest and Lungs
Assessment of the chest and lungs requires a clear understanding of pulmonary
anatomy, landmarks, and reference points. The ribs, clavicle, scapula, and vertebrae serve
as useful landmarks. Count ribs on the anterior chest by placing a finger in the substernal
notch and sliding the finger from the substernal notch left or right to the space between the
first and second ribs; count the intercostal spaces or ribs from that point. On the posterior
chest, the spinous process of the seventh cervical vertebra is quite prominent when the neck
is flexed forward. The first thoracic vertebra is just below the seventh cervical vertebra;
count the vertebrae from that point. Vertical reference points include the midsternal,
midclavicular, anterior axillary, midaxillary, posterior axillary, scapular, and vertebral lines
Techniques
The techniques of inspection, palpation, percussion, and auscultation are used to assess the
lungs. By convention, the examination is conducted from the patient’s right side.

14. Inspection
Inspect the chest through at least one complete inspiratory-expiratory cycle. Note chest wall abnormalities,
anteroposterior diameter, and skeletal abnormalities. Patients with longstanding obstructive airway disease
(e.g., asthma, chronic obstructive pulmonary disease [COPD]) often have an increased anterior- posterior
diameter (barrel chest). Patients with severe acute airway obstruction often use the accessory muscles to
breathe.

15. Chest Configurations.
A, Normal chest. B, Barrel chest.
Percussion
Percuss over the intercostal spaces (between the ribs) to assess lung density . Percussion over normal lung
tissue creates a loud, low-pitched, resonant note. Percussion over areas of lung with increased air volume
(e.g., emphysema) creates a very loud, low-pitched, hyperresonant note. Areas of consolidation (fluid)
produce a dull or flat percussion note (e.g., lobar pneumonia); shifting dullness is associated with freely
moving fluid within the pleural cavity (e.g., pleural effusion).
Indirect Chest Percussion.
Percuss to determine diaphragmatic location and excursion. Determine the location of the diaphragm with the
lungs fully expanded and with the lungs emptied. The difference between the two positions is the diaphragmatic
excursion. The diaphragm is located where the percussion note changes from resonant to dull. Normal
diaphragmatic excursion is about 3 to 5 cm for females and 5 to 6 cm for males. The diaphragm is elevated
when the lung on that side has collapsed (pneumothorax). The diaphragm is abnormally low with decreased
excursion in chronic obstructive airway diseases associated with chronic air trapping (e.g., COPD).

16. Palpation
Palpate the chest for masses, pulsations, crepitation.
The chest wall moves outward with lung expansion. Palpate for respiratory excursion by placing your hands on the patient’s
anterior or posterior chest. Place the hands so that the hands cover the lower ribs with moderate pressure (thumbs touching each
other, fingers spread apart) Instruct the patient to take a deep breath. With normal respiratory excursion, the hands pivot apart a few
centimeters at the thumbs.
Respiratory Excursion Checklist
□ Instruct the patient to stand.
□ Place the palms of the hands with thumbs together and pointing up at the center of the lower rib margin.
□ Spread the fingers apart and hold the chest with light pressure.
□ Instruct the patient to inhale deeply.
□ The hands should move apart slightly with the patient’s inspiration.
□ Report/record the results. (Example: Normal respiratory excursion.)

17. Auscultation
Auscultate the lungs with a stethoscope. On the posterior chest, auscultate between the scapulae
and vertebral column (not directly over the scapulae, vertebral column, or ribs)
Place the diaphragm of the stethoscope flat against the chest wall and instruct the patient to
breathe deeply and slowly through the mouth each time the stethoscope touches the skin. Assess at
least one complete respiratory cycle over each anterior and posterior lobe, comparing right and left
sides; assess each lobe more thoroughly if abnormalities are detected.
Pulmonary Auscultation Checklist
Anterior
□ Stand to the patient’s right.
□ Auscultate the right upper lobe (RUL).
□ Auscultate the left upper lobe (LUL).
□ Auscultate the right middle lobe (RML).
□ Auscultate the right lower lobe (RLL).
□ Auscultate the left lower lobe (LLL).
□ Report/record the results. (Example: Normal breath sounds.)

18. Posterior
□ Stand to the patient’s right.
□ Auscultate the RUL.
□ Auscultate the LUL.
□ Auscultate the RLL.
□ Auscultate the LLL.
□ Report/record the results. (Example: Normal breath sounds.)
Posterior Chest Auscultation.
Breath sounds are described as tracheal, bronchial, bronchovesicular, or vesicular. These breath sounds are distinguishable
through auscultation over areas of the lungs that normally produce the sounds (i.e., auscultation over the trachea, large central
bronchi, small airways just distal to the central bronchi, and small lateral airways identifies tracheal, bronchial, bronchovesicular,
and vesicular breath sounds, respectively) These sounds are considered abnormal, however, if heard over other areas of the
lungs. Other abnormal breath sounds include wheezes, rhonchi, and crackles. Abnormal breath sounds are
described by location (e.g., tracheal), timing (inspiration, expiration, or both), and duration (e.g., end-expiration).
Wheezes, high- pitched continuous musical sounds, are associated with airway inflammation and constriction (e.g.,
asthma, COPD, bronchitis, pneumonia, pulmonary edema). Rhonchi, coarse rattling sounds that change location with
cough, are associated with mucus in the airways. Crackles, intermittent crackling sounds of short duration, are
associated with fluid in the alveoli and airways (e.g., bronchitis, pneumonia, heart failure, pulmonary edema). A pleura
friction rub, created when the visceral and parietal pleurae rub together, sounds like creaking leather and is heard best a

19. Common terms
barrel chest: An anterior/posterior diameter ratio of 1:1; associated with diseases characterized by chronic air
trapping (e.g., COPD)
consolidation: Increased density (e.g., fluid)
crackles: Discontinuous, short-duration, bubbling sounds
crepitation: Crackling
dullness or flatness: Soft, medium-pitched percussion notes elicited over areas of increased density
egophony: Altered vocal resonance over areas of consolidation; the spoken “e-e-e-e” is transmitted as “a-a-a-a.”
funnel chest: Depression of the lower part of the sternum
hyperresonance: A loud, low-pitched percussion note elicited over areas of increased air volume
kyphosis: Abnormal curvature of the spine with backward convexity
pigeon chest: Anterior displacement of the sternum
pleural friction rub: Abnormal, creaking leatherlike sound produced when the inflamed surfaces of the visceral an
parietal pleurae rub against one another
resonance: The loud, low-pitched percussion note elicited over normal lung tissue
rhonchus, rhonchi: Coarse, rattling, abnormal breath sounds; often change location after coughing
stridor: Abnormal, high-pitched, continuous lung sounds heard over the upper airway
tympany: Loud, drumlike percussion notes elicited over hyperinflated areas

21. Cardiovascular System
The left ventricular apex (apical impulse or point of maximal impulse [PMI]) is normally
located at the intersection of the fifth intercostal space and the midclavicular line. The base of th
heart is located between the right second intercostal space medial to the sternum and the left
second intercostal space medial to the sternum.

22. Inspection
Inspect the chest for visible cardiac motions. Estimate the jugular venous pressure (JVP)
and assess the jugular venous waveforms by observing pulsations in the jugular vein with the
patient supine and the head of the bed elevated to 15 to 30 degrees.
The JVP is the vertical distance between the highest point at which pulsation of the
jugular vein can be seen and the sternal angle. Conditions associated with an elevated
JVP include congestive heart failure and fluid overload.

23. Palpation
Palpate for the PMI, local and general cardiac motion, and cardiac thrills. The PMI is easier to
identify if the patient sits up and leans forward than if the patient is supine. The PMI normally
has a diameter of about 2 cm and is located at the intersection of the fifth intercostal space and
midclavicular line (within about 10 cm of the midsternal line); use the pads of the fingertips to
locate the PMI. The PMI may be shifted downward and to the left in patients with diseases
associated with an enlarged heart (e.g., congestive heart failure). Pericardial friction rubs and
thrills may be palpable.
Point of Maximal Impulse (PMI)
□ Stand to the right of the patient.
□ Palpate for the PMI.
□ Report/record the results. (Example: Normal PMI.)

24. Heart Sounds and Murmurs
Heart Sounds S1-S4
•
□ Stand to the right of the patient.
•
□ Use the stethoscope diaphragm.
•
□ Auscultate the aortic area (2ICS RSB).
•
□ Auscultate the pulmonic area (2ICS LSB).
•
□ Auscultate the tricuspid area (LLSB).
•
□ Auscultate the mitral area (5ICS MCL).
•
□ Report/record the results. (Example: Normal S1 and S2, no S3 or S4.)

25. Murmurs
□ Stand to the right of the patient.
□ Use the stethoscope bell.
□ Auscultate the aortic area (2ICS RSB).
□ Auscultate the pulmonic area (2ICS LSB).
□ Auscultate the tricuspid area (LLSB).
□ Auscultate the mitral area (5ICS MCL).
□ Report/record the results. (Example: No murmurs.)

26. 2ICS, Second intercostal space; 5ICS, fifth intercostal space; LSB, left sternal border;
LLSB, left lower sternal border; MCL, midclavicular line; RSB, right sternal border.
Palpate for the radial, carotid, brachial, femoral, popliteal, posterior tibial, and dorsalis
pedis peripheral pulses. Rate the strength of the pulse as normal, diminished, or absent; a
rating scale may be used. The typical rating scale ranges from 0 to 4+, All the peripheral
pulses are diminished or absent when the patient is in shock.
Table 4-10. Peripheral Vascular Pulse Rating Scale
Rating Meaning
0 No pulse palpable
1+ Markedly impaired pulse
2+ Normal pulse
3+ Increased pulse
Rating Meaning
4+ Bounding (markedly increased) pulse

27. Auscultation
Auscultate the heart with a stethoscope. Use the diaphragm to assess higher- pitched sounds (e.g., S1, S2,
S3, S4); apply the diaphragm tightly to the skin. Use the bell to assess lower-pitched sounds (e.g., murmurs);
apply the bell loosely to the skin. A great deal of practice and experience are required to identify and
distinguish among the variety of normal and abnormal heart sounds. Heart sounds are very soft; it may help
to listen in a quiet area or to close the eyes to reduce conflicting stimuli.

28. Cardiovascular Auscultatory Areas.
The first heart sound (S1), created by mitral and tricuspid valve closure, is loudest at the cardiac apex
The second heart sound (S2), created by aortic and pulmonic valve closure, is loudest at the base of
the heart. The second heart sound can be split into distinct aortic and pulmonic components by deep
inspiration (physiologic splitting) or disease (e.g., pulmonary hypertension). The third heart sound
(S3), an abnormal heart sound associated with volume overload, is a soft sound heard just after S2.
The fourth heart sound (S4), an abnormal heart sound associated with pressure overload, is a soft
sound heard just before S1. S1 and S2 are assessed in all four auscultatory areas with the patient in
the upright and supine positions.
Note the relationship of breathing to the intensity of the cardiac sounds. Palpate the carotid artery to
help determine the timing of cardiac events and sounds (the S1 precedes and the S2 follows the
carotid pulse).

29. Other abnormal heart sounds include opening snaps (associated with mitral stenosis), ejection
clicks (associated with sudden dilation of the aorta and the pulmonary artery. Gallops are
exaggerated normal diastolic sounds; friction rubs are associated with pericarditis.
Murmurs (abnormal heart sounds caused by turbulent flow across a valve or the septum and
by diseases such as anemia and hyperthyroidism) are described according to their timing in
the cardiac cycle (systolic murmurs occur between S1 and S2; diastolic murmurs occur between
S2 and S1).

30. Terminology
bradycardia: A slow (<60 beats/min) heart rate
bruit: An abnormal auscultatory sound heard over a blood vessel; associated with turbulent
blood flow
crescendo-decrescendo murmur: A murmur that increases and then decreases in intensity
diastolic murmur: A murmur heard during diastole
ejection clicks: Abnormal heart sounds caused by dilation of the aortic and pulmonary arteries
gallop rhythm: Exaggerated diastolic heart sounds
opening snap: An abnormal diastolic heart sound caused by the opening of a stenotic mitral
valve
orthostatic hypotension: A fall in SBP of 15 mm Hg or more when the patient assumes a more
upright position

31. Pericardial friction rub: An abnormal sound created when the visceral and parietal pericardial
membranes rub against one another
Point of maximal impulse (PMI): Right ventricular thrust (apical impulse)
•S1: The first heart sound; produced by mitral and tricuspid valve closure
S2: The second heart sound; produced by aortic and pulmonic valve closure
S3: The third heart sound; produced by the sudden distention of the ventricular wall during
ventricular filling; associated with heart failure
S4: The fourth heart sound; produced by increased left ventricular end-diastolic pressure and
loss of ventricular distensibility; associated with hypertension

32. systolic murmur: A murmur heard during systole
tachycardia: A rapid (>100 beats/min) heart rate
thrill: Palpable vibrations produced by turbulent blood flow