Examination

By
Maged Albasmi, MSc, MD, PhD
Cardiovascular Medicine
 Respiratory Examination
• Introduction
• W - Wash your hands.
• I - Introduce yourself to the patient.
• P - Permission. Explain that you wish to perform a
respiratory examination and obtain consent for the
examination. Pain. Ask the patient if they are in any pain
and to tell you if they experience any during the
examination.
• E - Expose the necessary parts of the patient. Ideally the
patient should be undressed from the waist up taking
care to ensure the patient is not cold or unnecessarily
embarrassed.
• R - Reposition the patient. In this examination the patient
should be supine and reclined at 45 degrees.
• Peripheral Examination
• End of the Bed
• First look at the patient from the end of the bed for signs of breathlessness or distress.
• It is also important to look at the surrounding environment for sputum pots, nebulizers,
peak-flow meters, inhalers or oxygen tubing.
• Hands
• Look at the hands for clubbing (note this is best checked by looking at finger from the
side), tar staining and peripheral cyanosis.
• Examine for tremor and a carbon dioxide retention flap.
• Palpate the radial pulse to calculate heart rate. At this time also assess respiratory rate
and determine the pattern of breathing.
• Locate and palpate the brachial pulse and assess its volume and character, feeling for a
bounding pulse (which can be a sign of carbon dioxide retention)
• Face
• Look at the patient’s eyes and face for signs of Horner’s syndrome.
• Inspect the conjunctiva for signs of anaemia.
• Look at the lips and tongue for central cyanosis
• Lie the patient at 45 degrees and assess JVP.
• Palpate the cervical, supraclavicular and axillary lymph nodes
 Examination of the chest
• Inspection
• Look at the chest wall for:
• Chest wall deformity (e.g. barrel chest, pectus
excavatum/carinatum, scoliosis or kyphosis)
• Previous scars
• Use of accessory muscles
• Asymmetry of chest wall expansion (ask
patient to take deep breath) Next note the
pattern of breathing; is it regular, what is the
rate?
• Palpation
• Palpate the trachea by placing a finger either side of the
trachea and judging whether the distance between it and the
sternomastoid tendons are equal on both sides. Before doing
this warn the patient that this might be slightly uncomfortable.
• Assess chest expansion by putting the fingers of both your
hands as far round the chest as possible and then bring your
thumbs together in the midline. Ask your patient to take a deep
breath and observe whether the distance moved is the same
for both thumbs.
• Palpate for tactile vocal fremitus by placing the edge or flat
of your hand on the chest and asking your patient to say ‘ninety
nine’. This should be performed in a systematic fashion,
comparing each side and covering all areas of the front and
back of the thorax (including the axilla)
• Percussion
• Start percussion by tapping directly in the
middle of both clavicles. Then work down
the chest in a systematic manner
comparing each side and including the
axillary region. The finger on the chest
should always be placed in the intercostal
space, and there is no need to percuss more
heavily than is necessary as this can be
distressing for the patient.
• Auscultation
• Auscultation is then performed in a similar manner
using the diaphragm of your stethoscope.
• Ask the patient to take deep breaths through their
mouth and commencing at the apices work down the
chest in a stepwise manner, comparing each side with
the other and remembering to include the axillary
region.
• Listen for breath sounds - are they vesicular (normal)?
Next are there any added sounds (wheeze, crackles, or
rubs)?
• Assess vocal resonance: use the same auscultation
technique but ask patient to say ‘ninety nine’.
• The patient is then asked to lean forward and
the examination is then performed on the
posterior aspect of the patient’s chest.
• Finishing Off State that you would complete the
examination by:
• Checking for ankle oedema (cor pulmonale)
• Measuring the oxygen saturation
• Examining the contents of the sputum pot
• Finally explain to the patient that you have
finished your examination, thank them for their
cooperation and help them to get dressed.
 Abdominal Examination
• Introduction
• W - Wash your hands.
• I - Introduce yourself to the patient
• P - Permission. Explain that you wish to perform an abdominal examination
and obtain consent for the examination. Pain. Ask the patient if they are in
any pain and to tell you if they experience any during the examination.
• E - Expose the necessary parts of the patient. Ideally patients should be
exposed from xiphisternum to pubis (classically they should be exposed
from “nipples to knees”, but this is rarely done in practice to preserve patient
dignity). Ensure adequate privacy.
• R - Reposition the patient. In this examination the patient should be lying flat
with one pillow under the head. This is not possible with all patients so first
check if they are comfortable in this position.
• During the examination of the abdominal system a lot of information can be
obtained by looking for peripheral signs of gastrointestinal disease. The
examination is therefore split into a peripheral examination and then an
examination of the abdomen
• Peripheral Examination
• End of the Bed
• Look at the patient from the end of the bed for obvious jaundice, nutritional status, signs of pain
or distress, signs of easy bruising or weight loss.
• Are there any abdominal drains, stoma bags
• It is also important to look at the surrounding environment for sick bowls, food supplements,
special dietary notices and ‘nil by mouth’ instructions etc.
• Hands
• Examine the hands for palmar erythema, Dupuytren’s contracture, koilonychia and leukonychia.
• If appropriate (patient jaundiced or confused) examine for liver flap.
• Face
• Look at sclera to assess whether jaundiced and inspect the conjunctiva for signs of anaemia.
Also look for xanthelasma (chronic cholestasis), corneal arcus (hyperlipidaemia), parotid swelling
(alcohol abuse) and bruising.
• Look at the mouth to assess dentition, angular cheilitis (iron deficiency) and any presence of
aphthous ulcers (Crohn’s).
• Look at the tongue for any glossitis. A red and beefy tongue can indicate folate/B12 deficiency.
atrophic and smooth can indicate iron deficiency
• Look for signs of dehydration in the face and mouth (e.g. sunken eyes, dry mucous membranes)
• Chest
• Examining chest for spider naevi (>5 is abnormal) and gynaecomastia.
• Note distribution of body hair, particularly paucity of hair (liver disease).
 Examination of the abdomen
• Inspection
• First inspect abdomen from the end of the bed before
closer inspection at bedside. Initially look for general
signs such as weight loss.
• Then check specifically for:
• Asymmetry
• Abdominal distension (remember the 5Fs – flatus,
faeces, foetus, fat, fluid)
• Scars and striae
• Prominent veins
• Hernia
• Visible peristalsis (this is normally only seen in
chronic pyloric stenosis or intestinal obstruction
• Palpation
• Position: sitting on the patient’s right hand side. Ensure
your hands are warm. Ask patient if they have any pain or
tenderness.
• Begin with light palpation of the nine segments. If
patient has complained of pain begin at opposite side.
Observe patient’s face throughout palpation to ensure
that you are not causing pain.
• Light palpation is used to assess tenderness and
guarding (a sign of irritation of the peritoneum).
• Proceed next to deep palpation of the same nine
segments. Deep palpation is used to assess for masses.
• If appropriate, test for rebound tenderness (a sign of
peritonitis)
9 segments of the abdomen
• Palpation of organs
• Liver
• A normal liver extends from 5th intercostal space to
costal margin. It may be palpable in normal
individuals. Position your hand in the right iliac fossa
with fingers in an upward position facing the liver
edge (alternatively you can use the radial aspect of
your index finger). Press your fingertips inward and
upward and hold this position while your patient
takes a deep breath. As the liver moves downward
with inspiration the liver edge will be felt under
fingertips. If no edge is felt repeat the procedure
closer and closer to the costal margin until either the
liver is felt or the rib is reached.
• Spleen
• The normal spleen cannot be felt and only becomes palpable when it has
doubled in size. It enlarges from under the left costal margin towards the
right iliac fossa.

• Position the palmer aspect of your left hand around the back and side of the
lower rib cage. The fingertips of right hand are then positioned obliquely
across the abdomen pointing to the left costal margin towards the axilla
(again, you may use the radial aspect of your index finger). Press your
fingertips inward and upward and hold this position while your patient takes
a deep breath. As the spleen moves with inspiration the edge may be felt
under your fingertips. If no edge is felt repeat the procedure closer and
closer to the left lower rib cage until the costal margin is reached.
• If the spleen is not palpable, this procedure can then be repeated with the
patient rolled onto right lateral position with knees drawn up to relax
abdominal position. Palpate with your right hand while using your left hand
to press forward on the patient’s left lower ribs from behind. It could be
argued that this method should be used first, since very few patients have
spleens which have enlarged to occupy the right iliac fossa.
• Kidneys
• The kidneys are retroperitoneal, so not usually palpable
except in some thin individuals. To examine left kidney,
place the palmar aspect of left hand posteriorly under
left flank.
• Position the middle three fingers of right hand below the
left costal margin, lateral to the rectus muscle (opposite
position of left hand). Ask patient to take deep breath
and press both fingers firmly together. If the kidney is
palpable it will be felt slipping between both fingers.
• To examine the right kidney repeat the procedure with
your left hand tucked behind the right loin and your right
hand below the costal margin, lateral to the rectus
muscle.
• Aorta
• In thin patients’ or those with a dilated
aorta, the aorta can be palpated by placing
both hands on either side of the midline at
a point half way between the xiphisternum
and the umbilicus. Press your fingers
posteriorly and slightly medially and the
pulsation should be present against your
fingertips.
• Percussion
• Liver
• Begin by establishing lower liver edge.
• Place hands parallel to the right costal margin
starting at the same point as you began palpation.
• Repeat in a stepwise manner moving the fingers
closer to the costal margin until the note becomes
duller. This is the position of the lower liver edge.
• Next find the upper margin of the liver. It can be
located by detecting a change in note from the
dullness of liver to resonance of lungs.
• Spleen
• Begin by percussing the ninth intercostal
space anterior to the anterior axillary line
(Traub’s space). If the spleen is not
enlarged the sound will be tympanic. If it
is dull continue to percuss in a stepwise
manner moving hands towards right iliac
fossa.
• Ascites
• If ascites is suspected percuss across patients
abdomen (from midline to left flank) until the
percussion note changes from tympanic to dull.
• Mark that spot and then ask your patient to turn onto
their right side (if you are standing on right of patient)
. After 30 seconds repeat percussing from the right
flank towards the midline.
• If fluid is present it will have redistributed secondary
to gravity and therefore the area previously marked
as sounding dull to percussion will now be tympanic
• Bladder
• If the bladder is distended the suprapubic
area will be dull rather than tympanic.
Percuss from the level of the umbilicus,
parallel to the pubic bone.
• Auscultation
• Bowel sounds
• Place the diaphragm of your stethoscope
on the midabdomen and listen for gurgling
sounds. These normally occur every
5-10seconds however you listen for 30
seconds before concluding that they are
absent. Absent bowel sounds indicates
intestinal ileus. Increased bowel sounds
indicate bowel obstruction.
• Arterial bruits
• Place diaphragm of stethoscope over
aorta and apply moderate pressure.
• If a systolic murmur is heard this indicates
turbulent flow caused by atherosclerosis
or an aneurysm. Listen for renal bruits
2.5cm above and lateral to the umbilicus.
Then listen over liver and spleen.
• Finishing off
• State that you would complete the
examination by:
• Checking for any lympahdenopathy
• Examining the hernial orifices
• Examining the external genitalia
• Performing a digital examination of the
anus and rectum
• Performing a urinary ‘dipstick’ analysis
• Finally explain to patient that your
examination has been completed, thank
them for their cooperation and help them
to get dressed
Thank you