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

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

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

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. 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 • 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 • No gap • Insp > Exp Quality of breath sounds Vesicular breathing …Normal Bronchial breathing …Consolidation • Gap • Insp = Exp

32. Ant. Chest Auscultation Added breath sounds Asthma Wheezing… Crackles… Fine……… Medium… Coarse…… 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. 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 ….