CHEST Inspection

- No chest wall deformities, no scarring, everything appears

symmetrical and there are no signs of respiratory distress or use of
accessory muscles

Percussion
- Presence of air increases resonance
- Presence of underlying solid structure eg enlarged liver, lung
consolidation or collection of fluid in the chest -> reduced resonance
(duller)

Auscultation
- DO this while feeling pulse in neck, allows us to identify first heart
sound
Diaphragm – transmits mid and high pitched sounds better
Bell – transmits low pitched sounds better

CVS
Radial pulse
– normal = 60-100bpm (above = tachycardia, below = bradycardia).
Check for regular rate, rhythm and volume
- Note irregularly irregular pulse suggests atrial fibrillation
- DO you have any shoulder pain, assess for aortic regurgitation via
raising rapidly & supporting elbow – no collapsing pulse

Brachial & carotid pulse – normal character and volume

- Can assess character – normal, bounding, slow rising
- Bounding suggests high metabolic output eg overactive thyroid
gland
- Rapid low volume may suggest shock

Carotid pulse – nor bruits, normal volume and character

- Listen with the bell, if no bruits identified then feel pulse

Check synchonicity of the pulses eg looking for radial radial delay

- Could indicate subclavian artery stenosis, aortic coarctation

Blood pressure
- Check pulses of both brachial arteries first to ensure bp
measurement is not going to be affected by proximal arterial
obstruction.
- Intitally the kuff is inflated above the patient’s systolic bp and
compresses the brachial artery completely stopping blood flow = no
sound is heard
- Systolic pressure should be recorded at the point the Korotkoff
sound first appears – this sound occurs as the cuff pressure drops
below systolic and turbulent blood flow occurs due to the
compressed artery
 - Diastolic when the Korotkoff sound disappears – cuff pressure is
released below diastolic bp to allow normal blood flow without
turbulence as the artery is fully open

JVP – Two cm and intravascular volume appears normal

- Head turned left to 45 degrees, way to asses intravascular volume
- Jugular vein runs between the two heads of SCM
- Measure it vertically from the sternal angle
If cannot find JVP assess hepatojugular reflex, hold down on tummy (RUQ),
observe rise in JVP to above 4cm
Differentiating venous and arterial
- Venous has two peaks per cycle, arterial has one
- Dominant movement is inwards for venous, outwards for arterial
- Venous varies with respiration, arterial does not
- Venous varies on the patient position, arterial is independent of
patient position

The Heart
 Thrill – the vibration at the skin surface which can be felt – caused by
turbulent flow within the heart or in a peripheral vessel.
 Murmur – turbulent blood flow within the heart detected on
auscultation.
 Bruit – turbulent blood flow heard in a peripheral vessel on auscultation.

Inspection – look for pectus excavatum (depression of the sternum),

scoliosis or kyphosis of the thoracic spine. Any scars or visible apex beat.

Apex beat
- Feel quality of the beat, abnormally forceful may = left ventricular
hypertrophy
- Comment on position eg Fifth intercostal space inside the mid-
clavicular line

Heart Sounds
- Listen to first & second heart sounds, check for no murmurs, clicks,
snaps or friction rubs
- Listen with diaphragm then bell
1. Fifth left ICS at the midclavicular line (apex/mitral area)
2. Fifth left ICS at the sternal edge (tricuspid area)
3. Second left ICS at the sternal edge (pulmonary area)
4. Second right intercostal space (ICS) at the sternal edge (aortic area)
The first heart sound (S1) is created by closure of the mitral and
tricuspid valves and marks the beginning of systole. The second sound
(S2) represents closure of the aortic and pulmonary valves at the end
of systole.

Heart murmurs
Graded on a sclae of 1 to six.
Systolic murmur – aortic and pulmonary valve stenosis or mitral and
tricuspid regurgitation
Diastolic murmur – aortic and pulmonary valve regurguitation and
mitral or tricuspid stenosis

Manoeuvres
There are specific manoeuvres to enhance auscultation of heart
murmurs. Right sided murmurs are loudest on inspiration; left sided
murmurs loudest on expiration. This may be remembered with the
acronym “RILE”. For example, breath holding at the end of expiration
enhances aortic murmurs and breath holding at the end of inspiration
enhances pulmonary murmurs. Aortic regurgitation can also be
enhanced by having the patient sit forward. Mitral stenosis is enhanced
when the patient is rolled over on to the left side.

Respiratory System
 Anterior auscultation and percussion – can you please place your hands
on your hips
Posterior – can you please place your hand on opposite shoulders
Anterior chest – Patient resting at 45 degrees

Inspection
- Normal symmetrical chest shape and movements. No scars or
asymmetry. Normal sternum with no pectus excavatum or
carinatum
- Observe shape of chest, look for symmetry of chest and it’s
movements and for scars that may point to previous lung resection
surgery – usually posterior or lateral
- Asymmetry may be caused by khyphoscoliosis or loss of lung
volume. Asymmetrical movements on expansion may indicate
consolidation, pneumothorax or pleural effusion
- Look for pectus excavatum (a deeply depressed sternum) or pectus
carinatum (a prominent sternum, ‘pigeon like’ chest)
- Normal work of breathing, not requiring accessory muscle use –
internal intercostals, pec major, SCM, trachea centrality

Percussion – Normal resonant symmetrical lung sounds

- Percuss superior to inferior and left to right
- Need to percuss over the lung fields anteriorly, posteriorly and in
the mid axillae
- Normal is resonant in sound & feel and symmetrical
- First persussion is anteriorly over the clavicle without using a finger
to strike against it
- Dullness -> consolidation or pleural effusion, increased ->
pneumothorax or COPD

Auscultation – Nomral vesicular breathing sounds, no stridor, wheeze,

crackles or rubs
- Instruct the patient to breathe in an out through an open mouth,
this minimuses upper airway sounds & creates good air flow.
Ausculate symmetrically anteriorly and posteriorly, beginning high &
moving side to side. Include the supraclavicular fossae as listening
areas (for the apices) - use bell for this then back to the diaphragm
for other sounds
- Normal = VESICULAR – characterized by the expiratory phase that is
shorter & softer in duration that the inspiratory phase.
- If I suspected consolidation or effusion I would also test for vocal
resonance – ant and posterior - Increased = consolidation –
Decreased = pleural effusion

Stridor = loud inspiratory sound indicating extra-thoracic obstruction

Wheeze = musical, squeaky sounds, may vary in duration, timing & pitch.
Indicate airway narrowing & are characteristically heard in asthma &
COPD. Typically heard on expiration.
Crackles – discontinuous sounds, vary in pattern, timing and frequency.
Fine crackles characteristic of LHF. Medium crackles more characteristic of
bronchiectasis or infection.
Rubs – caused by inflamed and roughened pleural surfaces generating
friction as they move over each other during respiration. They are
creaking, sawing “to-and-fro” sounds that stop when the breath is held

Posterior chest expansion exam

- I’m just going to examine your chest movements now, this will
involve me putting my hands tightly around your back and asking
you to take deep breaths in and out

ABDO
Inspection
- SCARS & STRIAE, MASSES, DISTENSION, PULSATION, abdominal
distension, caput medusae, normal rise and fall of the abdomen with
respiration
LOWER THE BED
Palpation
- ASK ABOUT PAIN – examine painful area last
- Superficial palpation in each of the nine areas – No tenderness or
masses felt, no guarding
- Deep palpation – identify masses – describe in terms of location,
size, consistency (hard,firm,.
- An aortic aneurysm may be felt as a pulsatile mass in the
epigastrium that is also expansile. Align hands parallel to the aorta
on either side of it.

Liver
- Inhale and exhale deeply and regularly
- Start parallel to the costal margin at the level of the umbilicus
- Each inspiration push hand gently but deeply into the abdomen
where they are held in order to palpate the lver edge as it is pushed
down by diaphragmatic action
- Liver edge palpable just below the costal margin –smooth, uniform
and non-tender – or not palpable – Thin adults feel it

Spleen
- Enlarges inferiorly and diagonally from left to right of the abdomen
- Palpate with fingertips at 90 degrees to the costal margin, palpate
from the right iliac fossa & move towards the left hypochondrium.
- Notch of the spleen palpated

Kidney – Not palpable, no tenderness and no enlargement or masses felt

- Palpable when enlarged
- Place one hand in the renal angle and flex the fingers while pressing
down with the other hand over the opposite surface anteriorly
 - NOT palpable,

Smooth surface felt, no tenderness, enlargement or masses felt

Auscultation – Normal bowel sounds and no renal bruits

- Presence of bowel and stomach sounds listening to the diaphragm
of the stethoscope
- Normally to the left and below the umbilicus
- Bowel sounds are absent in the presence of an ileus
- Tinkling – high pitched & persistent bowel sounds occur with bowel
obstruction
- Check for renal bruits by listening on either side above the
umbilicus

If I suspected ascites I would assess for shifting dullness

PERCUSSION
- No percussion tenderness
- Changes from resonant to dull when the upper and lower borders of
the liver were reached

CN 2
- Visual acuity chart
- Visual fields = If a visual field defect was identified I would do
another test to map this out in each eye individually. REMOVE
Glasses
- Optic fundoscopy – to complete
- Pupillary light reflex – direct and consensual response
- Swinging test -> no relative afferent pupillary defect (paradoxical
dilation of pupil when light sone into it)
- Accommodation reflex – convergence and meiosis in both eyes
(constriction and convergence of pupil)

Oculomotor (III), trochlear (IV) and abducens (VI) nerves

- Check for ptosis (upper lid droop) and normal/abnormal eye position
- Keep your head still and follow my finger with your eyes, let me
know if you see two fingers at any time/ double vision or if you have
any pain
- H movement slowly
- Check for nystagmus, muscle palsy
- Check lid lag, ask the patient to follow your finger as it moves
downwards in the vertical plane in line with the nose

CN 5 – Trigeminal
- Touch cotton to neck first so they know what it will feel like and with
a neurotip
- Facial sensation – three divisions, test with cotton wool, then
pinprick. Compare each side with patient’s eyes closed.
 - Test corneal reflex if the patient complains of facial numbness – this
tests trigeminal & facial nerve.

- Mastication muscles – look for wasting in the temporal fossae,

palpate the masseter and temporalis muscles while relaxed and
clenched. Ensure the patient can hold jaw open against resistance

- Could also test the jaw jerk reflex. If I was looking for a
pseudobulbar palsy.

CN 7 – Facial nerve
- Controls muscles of facial epression
- Everything appears normal, all movements were symmetrical and
no asymmetry at rest
- Please raise your eyebrows, close your eyes and don’t let me open
them, smile and show me your teeth, purse your lips, blow out your
cheeks.
- Have you noticed any changes in your taste?

CN 8 – vestibulocochlear
- Repeat no.s whispered in one ear while gently moving finger back &
forth over the external auditory meatus of the opposite ear. If
hearing is decreased determine if sensorineural or conductive
hearing loss using tuning forks for Weber’s and Rinne’s tests.
- Rinnes place tuning fork on mastoid process and ask whether the
sound is louder behind or in front of the ear and mover it in front of
the air. This allows us to determine if air or bone conduction is
better. Normal for air conduction to be louder if bone is louder this
suggests conductive hearing loss
- Weber’s – base of tuning fork placed in middle of patients forehead
and patient is asked where they hear the sound. Normal to hear it in
the middle. Sensorineural hearing loss it is louder in normal ear in
conductive it is louder in the abnormal ear.
- To complete this examination I would also carry out otoscopy to look
at the tympanic membrane however we do not have this equipment

CNs 9 & 10 – Glossopharyngeal & vagus

Phonation and swallowing
- Can you please say the phrase British constitution – normal speech
quality and volume
- Open your mouth (look at soft palate) now say Ah. If paralysis
paralysed side does not move and midline of the palate is pulled
towards the normal side
- Say la la la
- Can you give a sharp cough
- Can you swallow
 - I would also assess the gag reflex if I suspected and lesion of cranial
nerves 9 or 10 due to abnormality of the previous tests, however
everything appeared normal.

Accessory nerve – CN 11
Trapezius – Ask the patient to shrug their shoulders, palpate the muscle
body & look for wasting. Then test strength by asking to shrug again and
push down on their shoulders
SCM – turn their head to one side while you resist them by trying to bring
the head gently back to midline. Observe for wasting of the opposite SCM.

Hypoglossal nerve
- Look at the tongue at rest on the floor of the mouth – NO
fasciculations or atrophy
- Ask patient to stick tongue out, will deviate to the weak side
- NO Weakness
- Press tongue against the wall of the cheek

Limbs
Inspect
- No scars, wasting, fasciculations or involuntary movements

Tone – resistance to passive movement of a limb

- Increased tone may be due to rigidity eg parkinson’s or spasticity eg
umn disease
- Rigidity – detected with slow passive movement - affects flexors &
extensors of a limb about equally
- Spasticity – detected with rapid passive movement, tone maximal at
the start & then decrease suddenly as the muscle is lengthened
(spastic catch). Most marked in flexors in the arms and extensors in
the legs
- Sudden stretching of a spastic muscle produces reflex contraction. If
stretch is maintained, further reflex contraction with repetitive
beating (clonus) occurs

Power (graded 0-5)

- (strength) determines presence and patterns of muscle weakness &
helps to localize the cause. Isolate the muscle being tested &
stablise the more proximal part of the limb.
- Upper motor lesion (eg stroke) patients have a pyramidal
distribution of weakness. This is where in the upper limbs the weak
flexor muscles are relatively stronger than the extensor muscles
and vice versa in the lower limbs. UMN lesion patients have
characteristic pyramidal distribution of weakness with weak upper
limb held flexed & close to the body & the weak lower limb held
extended and stiff so the patient scuffs their toes while walking.
- In those with peripheral or nerve root lesions, LMN weakness affects
isolated muscles or groups or muscles.
REFLEXES (0-++++) - ++ = normal, + = present but reduced
- Reinforce by asking the patient to clench their jaw just prior to
striking with the hammer. You can only grade a reflex as being
absent when you’ve tested with reinforcement

Pinprick sensation
- Use a clean safety pin – show the patient the difference between
sharp & blunt sides of the pin in an area where you think sensation
is normal eg over the upper sternum. Then ask the patient to
identify sharp or blunt – actually drying to detect sharp sensation
not blunt so be carful not to miss testing part.

Joint position
Start by testing in the great toes. Hold either side of the distal phalanx
with the fingers of one hand, and either side of the proximal phalanx with
the fingers of your other hand. Demonstrate an upward and downward
movement with that joint. Then test with the patient’s eyes closed and
ask patient to identify the direction in which the joint moves. Try not to
hold the digit over the joint as the pressure will allow false identification of
movement. There is no need to test more proximally if joint position
sensation is normal at the great toes. Otherwise, move proximally to the
metatarso-phalangeal joint and if necessary the ankle joint. Test joint
position sensation in the distal fingers in the same manner, and move
more proximally if this is abnormal.
Vibration

Demonstrate to the patient what vibration feels like by placing the

vibrating tuning fork (128Hz) on their sternum (set the fork vibrating by
striking a firm surface). Start by placing the vibrating tuning fork on the
interphalangeal joint of the great toe with the patients eyes closed. Ask
the patient to let you know whether they feel the vibration. You can test
the reliability of the patient’s response by randomly applying a non-
vibrating fork on the joint. There’s no need to test over more proximal or
upper limb joints if vibration sensation is normal in the great toes, but
move proximally if vibration sensation is absent.

Upper limb power

- Shoulders in chicken wing position don’t let me push them down
- Put your arms out like x for me – check elbow flexion, stabilisng
hand on the bicep, can you pull towards you. Then switch stabilizing
hand to the triceps – push away
- Wrist extension, push you arms out straight and bend your wrists
back. Just keep your wrists there ( I push on it with straight arm and
power from my shoulder)
- Finger extension – put your fands out like this for me and don’t let
me push them down
- Finger abduction – spread fingers apart – place my finger against
second metacarpo-phalangeal joint of index finger and say push out
against my finger
- Turn hand over and test thumb abduction – don’t let me push it
down
- Finger flexion at distal interphalangeal joing of the middle finger.
Place thumb over middle area and place finger of other had on distal
part of middle finger above this and pull towards you

Reflexes
- Knee
- Ankle
- Plantar – should curl down

- Biceps

- Supinator/brachioradialis – distal end of supinator

- Triceps – forearm across the abdomen with elbow flexed to about 90

degrees & strike the triceps tendon
Sensation
L1, 2, 3, 4,5 and S1 – test in notch initially then same on both sides, both
sharp and light

Also check if they can feel the vibration in the notch

History
- History of presenting complaint

-
- Past medical history – Have you had any medical problems before?
Have you ever been admitted to hospital before? Do you have any
conditions such as asthma, diabetes, hypertension?
- Have you ever had an operation
- How is your mental health?

Medication History
- Do you take any medications? And anything natural or over-the-
counter? How often do you know what dose?
Allergies – if food, do you carry an epipen? What happens when you have
s?
I’m just going to ask you some general health and lifestyle questions now?
Are you okay with that?
Social History
- Who is at home with you? Is your home dry and warm?
- How is your support system ?
- Do you cook and clean for yourself?
- Can you dress yourself?
- Do you work?
- Have you smoked before ?
- Do you drink alcohol?
- Have you ever taken recreational drugs
- What do you do for exercise?

Family Hx
- Do you have any conditions that run in the family?
- Parents, siblings, age at death
- No diabetes, stroke, cancer

Systems enquiry
I am now going to ask you a series of questions to ensure that we have
not missed any important problem affecting your health

1. General
- Sleeping patterns
- Weight patterns
- Appetite
- General sense of well-being
- General levels of energy
2. CVS
- Swelling of the feet and ankles
- SOB at rest or exertion
- SOB lying down or causing waking at night relieved by sitting
up/exta pillows
- Chest pain – what provokes it
- Pain in the calves or buttocks when walking
- Irregular or rapid heartbeat
3. Resp
- Sore throat or earache
- Cough – if yes, duration, periodicity and sputum?
- Sputum – colour, quanity
- Coughing up blood
- SOB at rest or on exercise
- Chest pain
- Noisy breathing
4. GI
- Changes in appetite
- Weight loss or gain, time of change in weight
 - Condition of teeth
- Difficulty swallowing
- Indigestion
- Abdominal pain, nausea or vomiting
- Change in bowel frequency or stool
- Character, frequency and colour of the stools
- Rectal bleeding
5. CNS
- Memory/cognition
- Headahce
- Difficulty walking
- Vision, hearing and speech
- Fits or altered consciousness
- Difficulty swallowing
- Weakness of muscles
- Numbness, pins and needles, pain or tingling
6. Endocrine
- Increased thirst? Increased frequencing of peeing -> in the day or at
noght
- Neck swelling
- Unusual heart beats
- Heat intolerance
- Menstural history
7. Musc
- Pain, swelling or deformity of joints? If so which joints?
- Backache
- Morning stiffness in arms, legs or back
- Muscle pain and tenderness
- Can you dress yourself without any problem?
- Can you walk up and down stairs without a problem

- Changes in mood

- Extra bruising or bleeding

Inspection
Anterior Chest – hands on hips
- No scars, no pectus excavatum or pectus carinatum, no visible
pulsations everything appears symmetrical and normal
Posterior Chest – cross your arms over and on your shoulders
- No scars or deformities, the spine looked normal and everything
looks symmetrical
Auscultation – If I suspected effusion or consolidation I would also test
vocal resonance

Tummy – normal rise and fall with respiration, no scars, striae, abdominal
distension, caput medusae or visible pulsations
Aorta was normal and not expansible