This document provides an outline for examining the respiratory and cardiovascular systems. It begins with a brief introduction and then covers the key steps of inspection, palpation, percussion, and auscultation for both systems. For each step, it describes the relevant examination techniques and signs to assess. The document provides a thorough yet concise guide to performing physical examinations of the respiratory and cardiovascular systems.

1. COLLEGE OF HEALTH AND ALLIED SCIENCES
DEPARTMENT OF PYSICIAN ASSISTANT STUDIES
INTERNAL MEDICINE I
GROUP 10
TOPIC : RESPIRATORY AND CARDIOVASCULAR EXAMINATIONS
AH/PAS/20/0046 AH/PAS/20/0094
AH/PAS/20/0047 AH/PAS/20/0095
AH/PAS/20/0048 AH/PAS/21/0009
AH/PAS/20/0049 AH/PAS/22/0132
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2. OUTLINE
 BRIEF INTRODUCTION TO HX & EXAMINATION
 RESPIRATORY SYMPTOMS AND EXAMINATIONS
• Inspection
• Palpation
• Percussion
• Auscultation
 CARDIOVASCULAR SYSTEMS AND EXAMINATION
• Inspection
• Palpation
• Percussion
• Auscultation
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3. INTRODUCTION
• The respiratory system examination aims to pick up on any respiratory pathology
that may be causing a patient’s symptoms, such as shortness of breath, cough,
wheeze, stridor, chest pains, fever or sweat at night, hemoptysis etc.
• The examination is often performed in order of Inspection, Palpation, Percussion and
Auscultation.
• The mnemonic WIIPPPE can be used:
• W- Wash hand and don PPE where appropriate
• I- Introduce yourself and establish rapport
• I- Identity of the patient
• P- Permission (consent and explain examination)
• P- Position at 45° or seated upright
• P- Privacy
• E- Expose chest fully when appropriate
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4. GENERAL INSPECTION
SURROUNDINGS
 At the foot end of the bed (if patient is
on bed)
 Pulse oximeter
 ECG monitoring
 Oxygen therapy
 Inhalers
 Nebulizer
 IV infusions
 Non-invasive inhalers
 Chest drains
 Food and drink supplement
 Sputum spot
PATIENT’S GENERAL APPEARANCE
• Well or unwell?
• Alert and oriented or drowsy and
confused?
• Comfortable at rest or in pain?
• Body habitus? Cachectic or Obese?
• Signs of obvious respiratory distress:
o Dyspnea/ tachypnoea
o Use of accessory muscles
o Pursed lip breathing
o Flared nostrils, intercostal/ subcostal
recession, tracheal tug (children)
• Breathing pattern
• Colour: Pale or cyanotic
• Obvious scars
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5. HANDS
Inspection & Palpation
 Clubbing : Perform Schamroth window test and consider respiratory causes:
 Abscess of lungs
 Bronchiectasis
 Cancer of the lung/ Cystic fibrosis
 Empyema
 Fibrosis
Cigarette tar staining
Temperature
Peripheral cyanosis
 Tremor : Fine tremor: caused by use of β-agonist drugs (e.g. salbutamol).
Flapping tremor (asterixis): Late sign of CO2 retention
 Wasting of small muscles of hand
 Especially dorsal interossei and thenar eminence
can be caused by a C8/ T1 lesion
 Hand signs of rheumatological conditions or steroid use
ARM: Palpate for Pulse & Blood Pressure (rate, rhythm, character).
Bounding pulse (CO2 retention)
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Tar stains.
Looking for a flapping tremor. Wrists are dorsiflexed and
fingers abducted

6. NECK
Inspection & Palpation
 Lymph nodes- swollen lymph is a sign of bacterial or viral infections
 JVP- respiratory causes of increased JVP:
 Tension pneumothorax
 Severe acute asthma
 Pulmonary Edema
Carotid Pulse (CO2 retention= bounding)
 Tracheal deviation
 normal = central
 deviated away =tension pneumothorax, large pleural effusion
 deviated towards = lung collapse, pneumonectomy
 Crico-sternal distance
 Distance should be 3 or 4 fingers
 Distance is shorter in hyper-inflated lungs (e.g. COPD)
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Sternal notch for deviation
Lymph node palpation
JVP and Carotid Pulse
Crico-sternal distance

7. FACE ( NOSE,MOUTH & EYES)
 MOUTH
• Look especially for candidiasis (common in
those on inhaled steroids or
immunosuppressants)
• Blue lips- peripheral cyanosis
• Tongue (bright red = CO poisoning)
• Central cyanosis under the tongue-
respiratory causes:
oPneumothorax
oPulmonary embolism
oPleural effusion
oPulmonary oedema
oCOPD
oAcute severe Asthma
oAcute respiratory distress syndrome
(ARDS)
 EYES
• Conjunctiva pallor: Evidence of
anaemia
• Iritis: TB, sarcoidosis.
• Conjunctivitis: TB, sarcoidosis.
• Mucous membranes in the nostrils
(dehydration)
 FACE
• Facial swelling
• SVC obstruction (usually due to
bronchogenic carcinoma)
• Smoker’s facies (Gaunt, increase
wrinkles around eye and mouth)
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8. CHEST (ANTERIOR)
Inspection
 Chest wall deformity
 Pectus excavatum (“funnel shape” e.g. Marfan’s syndrome)
 Pectus carinatum (“pigeon chest” e.g. severe childhood Asthma)
 Barrel Chest ( Asthma, COPD)
 Harrison’s Sulcus (Childhood asthma) -
 Breathing pattern
 Seesaw breathing (diaphragm in, abdomen out on inspiration; severe airway obstruction)
 Fail Chest/ paradoxical breathing ( fracture of 2 or more ribs anteriorly and posteriorly)
 Skin changes (Telangiectasia-radiation damage)
 Prominent Veins
 Trauma & Surgical Scars
 Thoracotomy - pneumonectomy or lobectomy
 Thoracoplasty - rib removal (commonly in old TB patients)
 Small scars in axillae ( previous chest drains)
 Radiotherapy scars
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Pectus excavatum
Pectus carinatum

9. CONT’D
Palpation
 Apex beat (may be impalpable in COPD, pleural
effusion)
 Tactile vocal fremitus- say ‘99’ while edges on your
hands are placed over the chest
 Increase vibration: Consolidation, tumor, lobar
collapse
 Decrease vibration: presence if fluid or air around
the lung e.g. pleural effusion, pneumothorax
 Right Ventricle heave (cor pulmonale)
 Chest expansion. Respiratory causes of reduced
chest expansion :
 Asymmetrical: pneumothorax, pneumonia and
pleural effusion would cause ipsilateral reduced
expansion
 Pulmonary fibrosis & COPD reduces lung
elasticity, restricting overall chest expansion
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10. CONT’D
Percussion
 Normal lung sounds ‘resonant’.
 Dullness is heard/felt over areas of i density
(consolidation, collapse, alveolar fluid, pleural
thickening, peripheral abscess, neoplasm).
 Stony dullness is the unique extreme dullness
heard over a pleural effusion.
 Hyper-resonance indicates areas of d density
(emphysematous bullae or pneumothorax).
COPD can create a globally hyper-resonant chest.
 Normal dull areas :There should be an area of
dullness over the heart which may be diminished in
hyper expansion states (e.g. COPD or asthma).
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Areas to percuss on the anterior chest

11. CONT’D
Auscultate
• Tracheal breath sound
• Bronchial breath sound
 Larynx, suprasternal fossa, around
6th, 7th cervical vertebra, 1st, 2nd
thoracic vertebra
• Bronchovesicular breath sound
 1st, 2nd intercostal space beside of
sternum, the level of 3rd, 4th
thoracic vertebra in interscapular
area, apex of lung
• Vesicular breath sound
(Most area of lungs)
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12. CONT”D
 Decreased or absent
 Decreased respiratory excursions
 Respiratory muscle weakness
 Obstruction of airway
 Consolidation
 Hydrothorax or pneumothorax
 Abdominal diseases: ascites, large
tumor
 Increased
 Hyperventilation
 Prolonged expiration
 Bronchitis
 Asthma
 Emphysema
 Coarse breath sounds
 Early stage of bronchitis or pneumonia
Adventitious sounds
 Crackles / Crepitations / Rales
 Rhonchi (wheezes)
 Pleural friction rub
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13. CHEST (POSTERIOR)
INSPECT
 Scars
 Radiotherapy tattoos
 Deformity- particularly kyphosis or
scoliosis
 Breathing pattern
PALPATE
 Expansion- repeat lateral expansion
 Lymph nodes- Cervical,
Supraclavicular
 Sacral edema (cor pulmonale)
PERCUSS
 Percuss the upper, middle and
lower zones in an S shape.
 Percuss the posterior thorax while
patient crosses his arms and both
hands rested on the shoulder
AUSCULTATE
 Use the diaphragm of the
stethoscope and let the patient
take a deep breath by mouth
 Start over supraclavicular fossa,
both sides and axilla
 Vocal resonance
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LEGS
 Peripheral edema
Cor pulmonale
 Easy bruising
 Calf swelling (DVT)
 Erythema nodosum- respiratory causes
Viral/ Streptococcal throat infections
Mycoplasma pneumonia infections
TB
Peripheral edema

15. CARDIOVASCULAR EXAMINATION
INTRODUCTION
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The Cardiovascular system examination aims to pick up on any cardiovascular pathology that
may be causing a patient’s symptoms, such as chest pains, rest pains, claudication, palpitation,
dyspnea, oedema, Palpitations, Dizziness & fatigue, syncope.
The examination is often performed in order of Inspection, Palpation, Percussion and
Auscultation.
The mnemonic WIIPPPE can be used:
W- Wash hand and don PPE where appropriate
I- Introduce yourself and establish rapport
I- Identity of the patient
P- Permission (consent and explain examination)
P- Position at 45° or seated upright
P- Privacy
E- Expose chest fully when appropriate

16. GENERAL INSPECTION
SURROUNDING
• Oxygen cylinder
• ECG
• IV infusions
• Catheter( volume and urine Colour)
• Mobility aids
• Pillows
• Chest drains
• Food and drink supplement
• Sputum spot
PATIENT’S GENERAL APPEARANCE
• Well or unwell?
• Alert and oriented or drowsy and
confused?
• Comfortable at rest or in pain
• Nutritional state: Cachectic or Obese?
• Colour: Pale or cyanotic
• Shortness of breath
• Obvious scars e.g. Trauma scars
• Any genetic abnormalities e.g Marfan
syndrome, turner syndrome
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Surgical scar

17. HANDS
Inspection & Palpation
 Xanthomata- hyperlipidemia (e.g familial hypercholesterolemia)
 Tobacco staining- coronary artery disease and hypertension
 Nail bed pulsation – aortic regurgitation
 Finger clubbing- cardiovascular causes are:
 Mitral stenosis
 Aortic stenosis
 Infective endocarditis
 Congenital cyanotic heart disease
 Splinter hemorrhage- trauma, infective endocarditis, sepsis, vasculitis
 Capillary refill time- to access peripheral perfusion
 Peripheral cyanosis- hypoxemia
 Janeway lesion- infective endocarditis
 Osler’s node- infective endocarditis
 Arachnodactyly. It is a feature of Marfan’s syndrome, which is associated with mitral/aortic valve prolapse
and aortic dissection
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Janeway lesions
Osler nodes
xanthomata

18. Peripheral Pulses
• Radial pulse(rate, character, rhythm and volume)
• Radio-radial delay (indicative of aortic aneurysm or stenosis)
• Collapsing pulse ( PDA, aortic regurgitation, coarctation)
• Radio-femoral delay(aortic coarctation)
• Brachial pulse (rate, character, rhythm and volume)
• BP measurement
• Carotid pulse
• Jugular Vein Pressure
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Radial pulse
Brachial Pulse
Carotid Pulse

19. JUGULAR VENOUS PRESSURE (JVP)
 Position the patient in a semi-recumbent position (at 45°).
 Ask the patient to turn their head slightly to the left.
 Inspect for evidence of the IJV, running between the medial end of the clavicle and the ear
lobe, under the medial aspect of the sternocleidomastoid.
 Measure the JVP by assessing the vertical distance between the sternal angle or angle of
louis and the top of the pulsation point of the IJV (in healthy individuals, this should be no
greater than 3 cm).
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Causes of raised JVP
 Right sided heart failure
 Tricuspid regurgitation
 Constrictive pericarditis
 Cardiomyopathy
 Biventricular failure
 Pulmonary Embolism

20. FACE, EYES & MOUTH
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FACE, EYE AND MOUTH
• Conjunctival pallor- anaemia
• Corneal arcus- in patients above 50yrs suggest hypercholesterolemia
• Xanthelasma- hypercholesterolemia
• Malar flush- mitral stenosis
• Central cyanosis- hypo-perfusion (hypoxemia e.g. right to left cardiac shunt)
• Angular stomatitis- iron deficiency
• Dental hygiene- infective endocarditis
Corneal arcus
Xanthelasma

21. CHEST
INSPECTION
• Scars
• Pectus excavatum
• Pectus carinatum
• Visible pulsations (indicative of
ventricular hypertrophy)
• Posterior chest wall
PALPATION
• Apex beat (5th intercostal space
midclavicular line)
 Displacement of the apex beat can occur
due to ventricular hypertrophy and mitral
stenosis
• Heave: It feels like an abnormally large
beating of the heart. It suggest right
ventricular hypertrophy.
• Thrill: It is a palpable murmur and feels like
a vibration.
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Apex beat
Surgical Scar

22. CHEST CONT’D
AUSCULTATION
• First and second heart sounds
• Extra heart sounds
• Pericardial rubs
• Murmurs
• Lung bases
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AUSCULTATION
• Palpate the carotid pulse to determine the first heart sound.
Auscultate ‘upwards’ through the valve areas using the
diaphragm of the stethoscope whilst continuing to palpate the
carotid pulse.
Repeat auscultation across the four valves with the bell of the
stethoscope

23. ACCENTUATION MANEUVERS
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• Auscultate the carotid arteries using the diaphragm of the stethoscope whilst the
patient holds their breath to listen for radiation of an ejection systolic murmur
caused by aortic stenosis.
• Sit the patient forwards and auscultate over the aortic area with the diaphragm of
the stethoscope during expiration to listen for an early diastolic murmur caused by
aortic regurgitation.
• Roll the patient onto their left side and listen over the mitral area with the
diaphragm of the stethoscope during expiration to listen for a pansystolic murmur
caused by mitral regurgitation. Continue to auscultate into the axilla to identify
radiation of this murmur.
• With the patient still on their left side, listen again over the mitral area using the
bell of the stethoscope during expiration for a mid-diastolic murmur caused by
mitral stenosis

24. LEG
• Palpate for sacral and ankle oedema- right ventricular failure
• Inspect the patient’s leg for evidence of Saphenous vein harvesting
• Auscultate the lung bases for inspiratory crackles.
oAuscultate the lung field posteriorly
 Coarse crackles –Pulmonary edema
 Absence air entry and stony dullness- pleural effusion
• Examine the abdomen for a pulsatile liver and aortic aneurysm.
• Check peripheral pulses, observation chart for temperature and O2, sats, dip
urine, perform fundoscopy
 Complete examination by thanking the patient, wash your hands and
record/ summarise.
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25. REFERENCE
• Macleod Clinical Examination Textbook.
• Oxford Clinical Medicine 10 .ed.
• Oxford Physical Examination Textbook
• Davidson Principles and Practice of Medicine
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26. THANK YOU
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