Clinical Skills

• Check temperature, sweatiness
• Palmar surface: for nodes, lesions, colour changes, thenar wasting and deformities
• Extensor surface: Vitiligo, yellow tar staining, Raynaud's phenomena, gangrene
• Nodules: rheumatoid nodules, gouty tophi, tendon xanthomata,
• Joint abnormalities: osteoarthritis, rheumatoid arthritis, SLE
• Check for ASTERIXIS. Ask the patient to maintain this position for 15 seconds.
• - This is a common and early finding in hepatic encephalopathy. However, it is not specific and may also occur in cardiac, respiratory and renal failure, as well as Wilson’s disease

• Anxiety
• Some otherwise healthy patients may have primary excessive perspiration (hyperhydrosis), which is an autosomal recessive condition commonly starting during adolescence.
• It must be distinguished from secondary hyperhydrosis caused by a variety of medical conditions, and which can start at any point in life. Causes of secondary hyperhydrosis
• include
• - hyperthyroidism,
• - menopause,
• - phaeochromocytoma,
• - hypoglycaemia,
• - neuropathies,
• - brain or spinal cord lesions, and
• - fever.
• Hyperhydrosis can be further categorised as localised or generalised

• View the fingers and nails from the front and then side on. Note the presence of;
• - Changes in colour, either diffuse or localised in the nail bed or plate.
• - Transverse bands or lines in the nail bed or plate.
• - Longitudinal lines in the nail bed or plate.
• - Dystrophic changes.
• - Infection.
• - Clubbing
• The capillary refill time is a crude measure of the adequacy of the peripheral circulation.

• Radial artery harvest
• Spider naevi
• Bruising or striae
• Needle track marks: may give important clues to intravenous drug use and infectious diseases (HIV, hepatitis B, hepatitis C), as well as bacterial endocarditis.
• Renal haemodialysis shunts: may be placed in the forearm. These arteriovenous fistulae usually appear as a large pulsatile blood vessel, commonly with a palpable thrill.
• Lymphangitis: is an inflammation of lymphatic channels occurring proximal to a site of infection, most commonly by Streptococcus pyogenes.
• #
• Blood pressure

• Incorrect cuff size is the most common error. A cuff that is too big will under-estimate, and a cuff that is too small will overestimate, blood pressure.
• The position of the upper arm in relation to the heart may influence the measured pressure by a simple hydrostatic mechanism. If the arm is raised the measured pressure will be lower and if the arm is lowered the pressure will be higher.
• An auscultatory gap is a temporary disappearance of the Korotkoff sounds just after the appearance of Korotkoff I (i.e. systolic pressure), the sounds then reappearing just above the diastolic value. This presence of a gap may result in under-estimation of systolic pressure if the cuff is initially inflated within the gap. The gap error is therefore overcome by estimating systolic pressure by palpation prior to auscultation.
• - The gap occurs in 20% of elderly hypertensive patients and is an independent risk factor for the development of cardiovascular disease.

• Determine the pulse rate, the rhythm, and note the presence of pulsus alternans and pulsus paradoxus.
• Determine respiratory rate.
• Feel both radial pulses simultaneously for any asynchrony (radial-radial delay).
• Feel the radial and femoral pulses simultaneously for any asynchrony (radial-femoral delay).

• Character and volume are poorly assessed by palpating the radial pulse;
• - the carotid or brachial arteries should be used to determine the character and volume of the pulse, as these more accurately reflect the form of the aortic pressure wave.
• # Patterns to check with radial pulse
• Collapsing (bounding) pulse: of aortic regurgitation
• Pulsus alternans: (alternating strong and weak pulse) of advanced left ventricular failure,
• 
• Pulsus paradoxus: During inspiration, the systolic and diastolic blood pressures normally decrease (because intrathoracic pressure becomes more negative, blood pools in the pulmonary vessels, so left-heart filling is reduced). Pulsus paradoxus is an exaggeration of this drop more than the normal 10 mmHg fall
• - seen in acute cardiac tamponade, chronic constrictive pericarditis, severe asthma attacks and acute respiratory failure.

• Orthostatic hypotension: is defined as a fall of more than 20mmHg in systolic pressure, and 10mmHg in diastolic pressure, within 3 minutes of standing.
• - Have the patient lie supine for 2-5 minutes then measure the blood pressure.
• - Then have the patient stand, and after two minutes, remeasure the pressure.
• A significant postural drop may be due to a range of autonomic and vascular disorders, hypovolaemia or medications, and with old age.
• #
• Blood pressure response to Valsalva: If you suspect, from the patient’s history or other exam findings, the presence of borderline heart failure, consider assessing the blood pressure response to a Valsalva manoeuvre.
• - This is a test for reflex autonomic control of the cardiovascular system through changes in intrathoracic pressure. It is a very good, but little known, test with high specificity and sensitivity for detecting impaired ventricular dysfunction.
• - The test is not used in overt heart failure, but for unmasking those patients where lesser degrees of ventricular impairment are considered possible. The procedure is not simple and therefore it is very important that you explain it adequately to the patient.

• Procedure: inflate the cuff to 15mmHg above the systolic pressure while listening over the brachial artery. Keep it at 15mmHg somehow
• - While continuing to listen and maintain the cuff pressure, ask the patient to strain against a closed glottis (Valsalva), as if bearing down to have a bowel motion. Instruct the patient to strain for 10 seconds. You should hear the Korotkoff sounds suddenly appear as the blood pressure rises in response to the strain. If the sounds do not appear, then it is likely the strain is insufficient and the test will need to be repeated.
• - At the end of the ten second strain, ask the patient to relax and breathe quietly and normally while you continue to listen for 30 seconds. then deflate the cuff and remove your stethoscope.
• 
• In normal patients, the Korotkoff sounds disappear with the relaxation, but then reappear a short while later as a baroreflex-mediated rebound, or overshoot in blood pressure, occurs (TOP).
• If significant left ventricular dysfunction is present, the heart will not be able to generate sufficient contractility to increase the blood pressure. There will therefore be no overshoot and Korotkoff sounds will not reappear following relaxation.

• 
• SKIN: Acanthosis nigricans are brown/black velvety plaques, often associated with skin tags, and typically occurring in the axillae, groin and back of the neck. The condition is due to epidermal thickening and hyperpigmentation.
• - most commonly in obesity, but may also occur as a heritable condition, in diabetes, Cushing’s syndrome, polycystic ovary syndrome, and malignancy.
• Lymph nodes:
• - Epitrochlear nodes; commonly enlarged in IV drug users, infectious mononucleosis, non-Hodgkin lymphoma, and chronic lymphocytic leukaemia.
• 
• Axillary nodes; can be divided into four groups;
• - Central nodes that lie along the chest wall high in the axilla, and midway between the anterior and posterior axillary folds. The next three groups drain directly into the central nodes;
• - Pectoral anterior nodes inside the lower border of pectoralis major, inside the axillary fold. These drain the anterior chest wall and much of the breast.
• - Subscapular posterior nodes along the lateral border of the scapula, deep in the posterior axillary fold.
• - Lateral nodes along the upper humerus draining the arm.

• Facies: Down's syndrome, acromegaly etc
• Hair
• Eyes: position and alignment, proptosis or exopthalmus
• Eyelids: xanthalasma, ptosis
• Conjunctiva: jaundice and pallor

• Scars
• Masses and swellings: Salivary glands, lymph nodes, others?
• Trachea: displacement,
• - Tracheal movement; With your finger resting on the trachea, note whether the trachea moves downwards with respiration. A downward movement with inspiration (tracheal tug) may be due to excessive pull on the trachea with diaphragmatic contraction secondary to chronic obstructive pulmonary disease (Campbell’s sign). It can also arise from the increased negative intrathoracic pressure generated by respiratory distress.
• - Note also any movement of the trachea with the heartbeat. A bobbing of the cricoid cartilage with each heart beat suggests an aneurysm of the aortic arch (Oliver’s sign).
• Thyroid: note to be filled in
• Carotid: listen for bruits, palpate,
• JVP; next slide

• Pulsations that occur in the right-sided veins reflect movements of the top of a column of blood that extends directly into the right atrium. This column of blood may be used as a manometer for the right atrium.
• The jugular venous pressure can be measured using either the external or internal jugular veins. Ideally however, the right side of the neck should be used, and the internal jugular vein used in preference to the external.
• 
• The right internal jugular has the most direct, unimpeded course to the right atrium and therefore more accurately reflects the pressure changes within the right side of the heart.
• Unfortunately, the internal jugular vein is deep to the sternomastoid muscle and therefore the upper level of its pulsation must be assessed by observing the transmitted pulsations through the muscle.
• This difficulty is complicated also by the frequent transmission of carotid artery pulsations which can be confused with the venous pulsation. If difficulty is encountered with internal jugular JVP assessment, then it is reasonable to measure the pressure from the external jugular vein.

• 
• By convention, the sternal angle is taken as the zero point, and the maximum height of pulsations in the internal jugular vein, which are visible above this level when the patient is at 45°, is measured in centimetres.
• In the average person, the centre of the right atrium lies 5 centimetres below this zero point

• Firstly, make a general inspection noting;
• a) the posture,
• b) chest wall deformities, shape and static symmetry,
• c) gynaecomastia,
• d) scars,
• e) other skin changes.
• Ask the patient to breathe deeply and note dynamic symmetry of movement with ventilation.

• Fowler’s position: Patients with severe respiratory disease or heart failure, will often sit upright, leaning forward, with elbows on their knees.
• - allows the patient to better utilise the power of the accessory respiratory muscles, will improve lung mechanics, and helps to treat orthopnoea.
• Dahl's sign: If Fowler's position has been adopted for some time, a chronic pigmentation on the extensor surface of the elbows and on the distal thighs may develop.
• #
• Three posture-related cardiorespiratory signs include;
• - Orthopnoea: shortness of breath that is aggravated by lying flat, relieved by sitting upright. Although suggesting congestive heart failure, orthopnoea can also occur with asthma, COPD, pneumonia, and pleural effusion.
• - Platypnoea: shortness of breath when sitting upright, relieved by lying flat, i.e. the opposite of orthopnoea. Uncommon, it may be the result of a right-to-left shunt (e.g. from pneumonia (?+ patent R → L septa?)) affecting the lung bases. The upright posture will increase shunting in these areas and may result in hypoxaemia.
• * If oxygen saturation is lower in the lying position, we call this orthodeoxia.
• - Trepopnoea: shortness of breath when lying on one side, but not the other. It is classically associated with unilateral lung collapse. By lying on the side, with the “good lung“ down, there is increased perfusion to this lung and, hence, better V/Q and diminished shunt.

• Pectus excavatum (funnel chest): is a developmental defect causing a localised depression of the lower sternum. Severe depression may cause displacement of the heart and compression of the right ventricle, which underlies the sternum.
• - Mild degrees may be symptomatic after vigorous cardiovascular exercise, with easy fatigability and reduced endurance.
• - More severe defects may cause tachyarrythmias due to compression of the right heart.
• - Limitation of chest wall movement may cause tachypnoea and a shift towards diaphragmatic breathing.
• Pectus Carinatum (pigeon chest): is an outward projection of the sternum and costal cartilages. Often the manifestation of chronic childhood respiratory disease, it may cause pain due to buckling of the ribs and sternum.
• - The chest is rigid and areas of local hypoventilation may increase the frequency of respiratory infections.
• - The heart is normally situated and there is no increase in arrhythmias.
• Kyphoscoliosis: a increased bowing (kyphosis) and lateral curvature (scoliosis) of the spine. The most common causes are either idiopathic, neuromuscular, vertebral, or connective tissue disorders.
• - The deformity can impair lung mechanics, leading to localised areas of hypoventilation. Even in those with normal lungs, this can lead to V/Q mismatch, hypoxaemia, pulmonary vasoconstriction, pulmonary hypertension and, eventually, right ventricular failure.
• Harrison’s sulcus: is a linear depression of the lower ribs just above the costal margins at the site of attachment of the diaphragm. It is often a sequelae of severe childhood asthma or rickets.

• Precordial palpation is used to identify:
• • The apex beat
• • Other pulsations
• • Thrills.

• The impulse results from systolic rotation of the heart (clockwise from above), initially during isovolumetric contraction, and then by the recoil force of left ventricular ejection into the aorta.
• These movements cause the left ventricle to swing forward, striking the chest wall, and resulting in a palpable impulse. Medial to the apical impulse, the right ventricle swings backwards with this clockwise rotation, and this movement may cause a retraction of the chest wall just medial to the apex.
• Normally the apex beat is about 1cm medial to the apex observed on chest X-ray.

• The apex beat is normally palpable in 25-40% of adults in the supine position, and in 50% of those in the lateral decubitus position.
• The palpability of the apex beat is diminished by obesity and emphysema.
• The apex beat is assessed for its location, diameter (<2cm), ventricle producing the impulse, and its character (Dynamicity, Duration, Multiple impulses).

• Turbulent flow across heart valves leads to vibrations that are audible on auscultation – these are called murmurs. The vibrations produced by some cardiac murmurs are so intense that these are palpable on the chest wall. Thrill is the term given to a palpable murmur.
• Usually thrills are low frequency vibrations. In grading the intensity of cardiac murmurs, a palpable thrill implies a grade of 4 or above (Levine classification).
• Palpate systematically with the flat of the hand. First over the apex and left sternal edge, and then the base of the heart. The presence of a thrill usually indicates an important, organic lesion.
• Thrills should be described according to their location, direction of radiation, duration, and timing in the cardiac cycle.
• - An early diastolic, left parasternal thrill is likely to accompany aortic regurgitation, and may best be felt with the patient leaning forward in full exhalation.
• - Apical thrills are more easily felt with the patient in the left decubitis position, bringing the apex closer to the chest wall.
• - The thrill of mitral regurgitation radiates to the axillae, but may also radiate to the left parasternal edge, or the base of the heart.

• The most commonly performed manoeuvres are;
• Inspiration: increase venous return to the right atrium respiration,
• Valsalva strain: rise in intrathoracic pressure reduces venous return and initially will cause emptying of pulmonary veins into the left atrium.
• Standing: decrease venous return and, like Valsalva, decrease filling to the ventricles
• Exercise
• Squatting: immediate increase in venous return and an increase in aortic pressure
• Sustained isometric handgrip: increase blood pressure
• Arterial occlusion:

• Inspiration will increase venous return to the right atrium and - by expanding pulmonary vasculature - will reduce the return to the left atrium.
• All events relating to right-sided flow will therefore intensify during inspiration. These include a rightsided S3, S4, and pulmonary as well as tricuspid murmurs.
• - Carvallo’s sign is an increase in intensity of a tricuspid regurgitation murmur in response to inspiration.
• - The only exception to this rule is the pulmonary ejection click which will not intensify.
• - Sitting or standing may exaggerate the effect of inspiration on venous return and this may be useful if the effects are otherwise unclear.
• Because of the increased right-sided flows, inspiration will also delay pulmonary valve closure and, because of the reduced left-sided return, will hasten aortic valve closure.

• The Valsalva is a forced expiration against a closed glottis.
• The rise in intrathoracic pressure created by this manoeuvre reduces venous return and initially will cause emptying of pulmonary veins into the left atrium.
• The reduced filling will decrease ventricular volume and this will have an effect to aggravate the lesions of hypertrophic obstructive cardiomyopathy and mitral valve prolapse.
• - in HOCM the obstruction will begin earlier as the smaller ventricle allows the anterior mitral valve leaflet to contact the septal hypertrophy earlier. This will increase the intensity of the systolic murmur.
• - In mitral valve prolapse, the reduced ventricular volume will allow the prolapse, click and murmur to begin earlier.
• As soon as the Valsalva is released there is an immediate increase in venous return and therefore right-sided lesions will return immediately to baseline within a few heart beats.
• In contrast, leftsided lesions will return to baseline after a delay.
• *A Valsalva should not be performed in the presence of myocardial ischaemia or acute coronary syndrome.

• Standing: will decrease venous return and, like Valsalva, decrease filling to the ventricles.
• - The mitral valve prolapse click and murmur will therefore occur earlier and in HOCM obstruction will occur earlier resulting in an earlier systolic murmur whose intensity will increase according to the gradient produced.
• Squatting: produces an immediate increase in venous return and an increase in aortic pressure. The effect of this is to increase the filling volume on both sides of the heart and to increase blood pressure.
• - In the opposite fashion to standing, the murmur of HOCM will decrease and the murmur and click of mitral valve prolapse will occur later.
• - In patients who are unable to squat, passive bending of the knees towards the abdomen may achieve the same result.

• Walking will increase cardiac output and therefore increase blood flow through the cardiac valves.
• - As long as auscultation takes place immediately, before the heart returns to baseline, this may be sufficient to improve the audibility of soft diastolic murmurs such as mitral stenosis.

• Bilateral isometric handgrip applied for 30-60 seconds will increase blood pressure and this will increase the murmurs of aortic regurgitation and mitral regurgitation.
• - The combination of a squat and bilateral handgrip may bring out very soft, otherwise inaudible aortic regurgitant murmurs. The increased ventricular filling pressures will also intensify an S3 and S4, as well as having a similar effect to squat on HOCM and mitral valve prolapse.

• This is the bilateral inflation of sphygmomanometer cuffs on the upper arms to about 20mmHg above systolic pressure for 20 seconds.
• The effect on aortic impedance is to intensify mitral and aortic regurgitant and VSD murmurs. This may be an easier test to perform than squatting.

• The apex of each lung rises approximately 2-4cm above the inner third of the clavicle.
• The lower border of the lungs crosses the 6th rib at the midclavicular line (MCL) and 8th rib at the mid-axillary line.
• 

• The right lung has three lobes (upper, middle and lower) and the left lung has two (the upper and lower lobes). Each lung is divided in half by an oblique fissure which follows a line from the T3 spinous process obliquely down and around the chest to the 6th rib in the MCL.
• - The right lung is further divided by a horizontal fissure.
• 
• Anteriorly this fissure runs close to the 4th rib and meets the oblique fissure in the mid-axillary line near the 5th rib, thus dividing the right lung into upper, middle and lower lobes.
• - The right middle and upper lobes, and the left upper lobe are represented on the anterior chest.
• 
• Posteriorly the upper lobes occupy left and right apices down to mid-scapulae and the lower lobes occupy the remainder of the posterior chest from the mid-scapulae to the diaphragms.
• - The right middle lobe is not represented on the posterior chest.
• 

• 
• The diaphragm is located on the right at the T10 level, ranging from T7 on full expiration to T12 on full inspiration. On the left it is situated at T9, with a range from T6 on full expiration and T12 with full inspiration.

• The spinous process C7 is called “vertebra prominens”. It is the most prominent spinous process and the end of the cervical lordosis.
• When attempting to define the surface landmarks, use C7 as a starting point from which lower vertebral levels can be determined.

• Dyspnoea is difficulty breathing, clinically indicated by increased breathing frequency and the use of accessory muscles.
• Hyperpnoea is an increase in respiratory rate and depth, and may be a compensatory process in response to metabolic acidosis.
• Cheynes-Stokes respiration is a form of periodic breathing in which respiration waxes and wanes. Classically associated with congestive heart failure
• - resp rate is irregular; it builds up and gets heavier before ceasing for 15 seconds
• Abdominal paradox is a sign of diaphragmatic fatigue. Where the chest wall and abdomen move asynchronously, causing a “rocking motion”.
• - It may be caused by upper airways obstruction or bilateral diaphragmatic weakness
• - can be confirmed by bimanual palpation; placing one hand on the chest and the other on the abdomen. The sign has a very high sensitivity (95%) and specificity (71%) for predicting impending respiratory failure.
• Respiratory alternans is an intermittent form of paradox that may be present if the diaphragm is mildly impaired; the diaphragm may function normally for a few inspirations and then fatigue for a few.
• Hoover’s sign is a paradoxical inward inspiratory movement of the lateral rib cage and occurs in almost 80% of patients with chronic obstructive pulmonary disease.
• - It is the result of direct traction by the flattened diaphragm on the lateral rib margins pulling the ribs towards the midline. Consequently, the subcostal angle (the angle between the xiphoid and the right/ left costal margins) becomes more acute.
• Intercostal retraction: normally the intercostal spaces are drawn mildly inward on inspiration and outward on expiration. An exaggeration of inspiratory retraction can occur in patients with restrictive or obstructive disease.

• Tenderness: Localised pain suggests a rib fracture, which may be due to osteoporosis, tumour metastasis or recurrent coughing.
• Pleural friction rubs: Inflamed pleural surfaces may become roughened, lose their lubricating surfaces, and rub together during lung movement. Sometimes their rubbing together can be felt. It is described as similar to two pieces of dry leather rubbing together.
• Vocal fremitus: is a palpable low frequency chest wall vibration similar to a cardiac thrill, but generated by the spoken voice and transmitted through the lung to the chest wall. It is traditional to assess changes in fremitus by asking the patient to say “99”, a practice that arose because of a misunderstanding when English speakers heard German physicians asking their patients to say “99” in German - “neun und neunzig”. By translating the phrase into English, however, there was a loss of the dipthong “eu” which is pronounced as in the “oy” of “toy”, “boy” or “Toyota”, or the “oi” of “coin”. This translation meant a loss of low frequency spectral energy which, in theory, is important for the generation of palpable vibrations. It is still not clear whether there is any real clinical value in using a phrase such as “toy coin” or the traditional “99” for vocal fremitus.
• The palpable vibrations are low frequency, in the range 100-200Hz. For this reason, fremitus is often more obvious in men who have a deep voice. In certain pathological conditions fremitus may be increased and in other conditions decreased.
• Therefore fremitus assessment requires a comparison of one side with the other, and an appreciation that an apparent diminution on one side may represent a true abnormal decrease on that side, or an abnormal increase on the other. It is clearly important, if you can, to establish the abnormal side in order to interpret the fremitus findings. The abnormal side might be suspected from the observation of inspiratory restriction on that side or some other findings on history or examination.
• A solid will transmit vibrations more easily than air-filled lung and therefore vocal fremitus will increase if there is a solid communication, such as consolidation, between the bronchus and the chest wall. Although all frequencies are transmitted through to the chest wall (both high and low), it is the transmission of the low frequencies that is felt as fremitus.
• Fremitus will be reduced in areas where there is an obstruction in the bronchial system preventing conduction of sound from the larynx, or if the lung is displaced away from the chest wall by air, fluid or solid material in the pleural space.
• Although rarely noted in modern texts, the degree of fremitus varies over the normal chest. It is usually more intense over the right upper lobe than the left since the trachea lies in immediate contact with the apex of the right lung, whereas on the left it is separated by 3cm due to the interposition of the aorta. Equal fremitus over left and right apices may therefore be an abnormal finding. For this reason it is very important to gain examination experience in many normal people in order to evaluate fremitus in pathology.

Remember it needs doing, but no FC material

• Lung sounds are sounds generated within the lung by breathing. They include breath sounds and adventitious sounds.
• Breath sounds are the sounds produced within the lung by air movement through the airways and heard with a stethoscope at the surface of the chest. They are the background sounds upon which adventitious sounds are superimposed.
• - Breath sounds are categorised as tubular, vesicular, bronchial, bronchovesicular or (rarely) amphoric.
• Adventitious sounds are sounds generated by vibration of solid lung tissue. They include crackles, wheezes, rhonchi and pleural friction rubs.
• Transmitted voice sounds are not lung sounds as such, but are those heard with a stethoscope when the patient speaks. These sounds are therefore generated by the larynx and transmitted through the lung. Transmitted voice sounds include bronchophony, pectoriloquy, egophony and the “E to A change”.

• Tubular breath sounds = large airways
• - When it passes through the normal air-filled lung they are acoustically filtered, frequencies over 200Hz are diminished and the maximum intensity of sound is at 100Hz
• These filtered sounds are Vesicular breath sounds
• - It is soft/quiet (diaphragm exaggerates high frequencies at the expense of intensity)
• - There is no silent pause between inspiration and expiration.
• - It has an audible expiratory phase that is usually shorter than inspiration since expiratory sounds tend to have more high frequencies in the last 2/3rds of expiration. The I:E ratio is therefore 3:1 or 4:1 as opposed to 1:1.
• With normal ageing the pitch and intensity of vesicular breath sounds decrease.

• If tubular breath sounds reach the chest wall without being filtered by air-filled lung (such as through consolidated lung), the breath sounds heard through the stethoscope will be similar to tubular sounds.
• - These are called bronchial breath sounds.
• In normal people tubular (bronchial) sounds can be heard over the trachea. Elsewhere the presence of a tubular sound suggests the presence of airless, consolidated lung.
• N.B. The more proximal airways to the consolidated region need to be patent for the generation and then conduction of tubular sounds to the chest wall.
• Bronchial sounds are heard over areas of consolidation, since consolidated lung better transmits the high frequency sounds that are normally filtered by the air-filled lung.

• Consolidation reflects either alveolar collapse or fluid-filled alveoli.
• - Alveolar collapse occurs with pleural effusion, when the amount of fluid is large enough to compress the alveoli, but too small to compress the airway.
• - Alveolar fluid filling occurs from pus as in pneumonia, from blood as in alveolar haemorrhage or serum as in pulmonary oedema.
• The important characteristics of a bronchial sound is that:
• - It is louder than a vesicular sound because of the added higher frequencies.
• - It has a hollow blowing quality, almost like Darth Vader.
• - There is a silent pause between inspiration and expiration.
• - It has an expiratory phase that is as long as inspiration (an I:E ratio of 1:1).

• 
• Bronchovesicular breath sounds are transitional sounds heard normally over the sternal area (i.e. overlying the large airways) and upper thoracic spine posteriorly in normal people. They possess characteristics of both vesicular and tubular breath sounds. Their presence may indicate a small pleural effusion or early consolidation.
• The important characteristics of a bronchovesicular sound are that;
• - It is louder than a vesicular sound, but softer than a tubular sound.
• - There is no silent pause between inspiration and expiration (like a vesicular sound).
• - It has an expiratory phase that is as long as inspiration (an I:E ratio of 1:1) - like a tubular sound.

• An amphoric breath sound is a rarely heard low-pitched sound resembling that caused by over the opening of a bottle. It has also been referred to as cavernous breathing.
• The sound is generated within an area of alveolar destruction, such as a large emphysematous bulla, and is never heard in the presence of alveoli.

• In chronic bronchitis and asthma the intensity of a breath sound at the mouth directly correlates with the degree of spirometric airway obstruction. This is because in these conditions there is increased airflow turbulence with increasing obstruction.
• - In chronic bronchitis there is therefore a paradoxical increase in loudness at the mouth, but a decrease in intensity at the chest wall.
• It is important to understand here that we are not describing wheeze or stridor, but the breath sound itself. In fact, the breath sound loudness may predict degree of airflow obstruction more reliably than the presence of wheeze.
• - In emphysema the mouth breath sounds are quiet since the turbulence generating the breath sound is less because the airway narrowing is absent.
• Noisy mouth breathing suggests, therefore, a diagnosis of chronic bronchitis or asthma over emphysema.

• Adventitious sounds are sounds additional to, and superimposed upon, the breath sounds. They are caused by vibrations in solid structures and are classified as
• - continuous (if they are long),
• - discontinuous (if they are brief) or
• - pleural rubs.

Continuous adventitious lung sounds (CALS) are defined as those lasting longer than 250msec, however (in reality) some last for a shorter period of time. CALS include;

• Wheezes which are high-pitched hissing sounds with a dominant frequency usually more than 400Hz.
• - They are caused by obstruction within the airway, either from bronchial muscle spasm, secretions or bronchial oedema.
• - The worse the obstruction, the higher the pitch and longer the wheeze. Pitch is not related to the size of airway and therefore tells you nothing about whether the obstruction is central or peripheral.
• - A wheeze requires sufficient airflow in order to be produced, thus as flow falls to critical levels the wheeze will quieten. A quiet chest in severe asthma is potentially a life threatening emergency.
• Rhonchi are low-pitched snoring sounds with a dominant frequency usually less than 200Hz.
• - They are caused by fluid (e.g. blood, pus, sputum) within the airway.
• Stridor is a loud, high-pitched inspiratory sound related to upper airway obstruction, such as from epiglottitis, vocal cord dysfunction or foreign body.
• - Expiratory stridor can occur with lower airway obstruction from a foreign body (e.g. a peanut).

CALS generated within the thorax usually occur in expiration or both inspiration and expiration. They do not usually occur during inspiration only. Purely inspiratory CALS are usually produced by airway obstruction outside the lung (e.g. upper airway obstruction), although a late inspiratory squeak may be caused by the reopening of partially collapsed airways and is common in interstitial lung disease (e.g. pulmonary fibrosis), coexisting with late inspiratory crackles.

• Discontinuous adventitious sounds last less than 250msec and are called crackles (formally referred to as rales or crepitations).
• Crackles usually occur during inspiration, they may be caused by bubbling secretions or the popping open of closed airways.
• Crackles should be assessed for their timing within the respiratory cycle, their location, pitch, amplitude, repeatability, and the effect of cough.
• #
• Expiratory crackles are less common than inspiratory crackles, but may be heard in some patients and are an important sign;
• - In obstructive causes (e.g. bronchitis or bronchiectasis), the crackles are early expiratory, coarse, gravity independent and profuse. They decrease with coughing.
• - In restrictive processes (e.g. pulmonary fibrosis or connective tissue disease), they are mid, or late expiratory, gravity dependent, and scanty. They are unaffected by coughing.

• Vocal resonance is the auscultatory equivalent of vocal fremitus, but various conditions affect fremitus and resonance differently.
• - Vocal fremitus is the palpable transmission of low frequency vibrations from the spoken voice.
• - Vocal resonance is the audible transmission of high frequency vibrations from the spoken voice. Vocal resonance has a similar clinical significance as bronchial breathing.
• Voice sounds → air-filled lung acts as a filter to reduce high frequency components. Because high frequencies are removed by normal lung, a stethoscope placed on the chest of someone speaking will transmit muffled unintelligible sound.
• Consolidated lung is better at transmitting high frequencies than air-filled lung and therefore voice sounds transmitted through consolidation will be more clearly heard, although still not necessarily understood.
• There are four ways in which the augmentation of the vocal high frequency conduction by consolidation can be heard and assessed; bronchophony, egophony, the “E to A change” and pectoriloquy. The underlying physiology in each is similar.
• *Details not necessary. But of the 4 methods, egophony and the E to A change are probably the most sensitive signs of early pulmonary consolidation.

• Inspect for:
• - Spinal deformities (kyphosis/scoliosis).
• - The presence of interspace retraction.
• - Scars from previous surgery.
• - Symmetry of upper lobe expansion by looking over the patient’s shoulders for symmetric elevation of the clavicles with deep inhalation.
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• Palpation:
• - Assess lung expansion
• - Assess vocal fremitus
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• Percussion:
• - Percuss along the trapezius from the shoulder to the base of the neck. There should be an area of resonance between the muscles of the neck and shoulder (Kronig’s isthmus) on each side. Loss of this normal resonance suggests upper lobe disease.
• - Ask the patient to cross their arms, drawing the scapulae laterally and exposing a greater area of the posterior chest wall. Then percuss in the pattern seen below
• 
• - *Diaphragm percussion
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• Auscultation:
• - listen over the same places as above diagram
• #
• Check sacral oedema; press over the sacrum with your finger for 2-3 seconds then release.

* N.B. Abdo exam auscultate before percussion and palpation with bed flat

• 1) Make a general inspection of the abdominal wall for skin lesions, scars and to identify surface contours, movements and pulsations.
• 2) Auscultate to identify bowel sounds first and then bruit.
• 3) Percuss the abdomen to identify the distribution of solid, liquid and air, and to note percussion tenderness.
• 4) Using gentle palpation examine for tenderness and guarding and
• 5) using deeper palpation search for masses.
• 6) Having completed a general examination of the abdomen, carry out a focused individual examination of the liver, spleen, kidneys, bladder and aorta.
• Finish by examining for herniae, the genitalia, and finally carry out a rectal examination where indicated.

• Location
• Tenderness
• Size and shape
• Surface – regular or irregular
• Edge – regular or irregular
• Consistency – hard or soft
• Mobility and movement with inspiration
• Pulsatility
• Can you get above the mass?
• #
• Abdominal masses may lie either within the abdomen or within the anterior abdominal wall. To determine which of these is most likely, ask the patient to cross the arms and sit up halfway. An intra-abdominal mass will disappear as the now rigid abdominal wall pushes the mass back into the abdominal cavity. A mass within the layers of the abdominal wall will, however, remain unchanged.

• Carnett’s sign uses induced guarding to differentiate the tenderness of an inflamed intra-abdominal viscus from that of an inflamed abdominal wall.
• • Localise by palpation the area of tenderness.
• • Maintain pressure over the area of tenderness while you ask the patient to raise their head off the bed, thus contracting their abdominal muscles.
• • Ask whether there is any change in tenderness with the head raising.
• Pain that results from abdominal wall pathology will increase because of the added wall tension, but pain from an intraabdominal viscus will decrease because the abdominal wall guards the area of tenderness from the palpating hand.

• Rebound tenderness: when abdominal wall having been compressed slowly, is then suddenly released and this release causes a sudden stab of intense pain.
• - Although the sign suggests peritonitis (also known as Blumberg’s sign), the method is not recommended since the elicitation of percussion tenderness is a kinder, less painful method yielding similar information.

• The “closed eye sign” describes the face of a patient with non-specific abdominal pain (i.e. someone with no clearcut intra-abdominal pathology) who will often keep the eyes closed during palpation of the abdomen.
• This is the converse of a patient with true intra-abdominal pathology, who will tend to keep the eyes open, constantly monitoring what you are doing.
• Surprisingly, this is a useful sign - in a study of 158 patients admitted for abdominal pain, eyes were closed in 7% with true pathology and 80% with no pathology. 80% of patients with closed eyes were female and usually young.

• The liver span is the distance in centimetres between the upper hepatic border in the right mid-clavicular line, as determined by percussion, and the lower border as determined by percussion or palpation.
• The normal span is 10 -12cm and, in general, clinical examination often underestimates this value. Importantly, a diseased liver is not always enlarged and an enlarged liver is not always diseased.
• As a measure of hepatomegaly, the span is more important than the position or palpability of the lower edge. Thus a normal sized liver may be lower, and hence easily palpable, if the diaphragms are flattened by the lung hyperinflation of emphysema. Thus a palpable liver is not necessarily enlarged.

• The gall bladder is seldom palpable, even in pathological circumstances. As with liver palpation, the gall bladder is best felt with firm pressure as the patient inspires.
• - It may occasionally be felt below the right costal margin where it crosses the lateral border
• of the rectus muscle. This surface marking coincides with the tip of the 9th rib.
• []
• If biliary disease is suspected, the palpating hand should be placed perpendicular to the costal margin, feeling medial to lateral. If palpable, the gallbladder will be a bulbous, round, focal mass, which moves downwards on inspiration.
• If cholecystitis is suspected, Murphy’s sign should be sought. The sign has a 50-80% sensitivity and specificity for cholecystitis.
• A positive Murphy’s sign is present when inspiration is cut short as the inflamed gall bladder descends and pushes against the examiner’s hand

• Courvoisier’s law states that if the gallbladder is enlarged and the patient is jaundiced, then obstruction is more likely to be caused by tumour than gallstones.
• - This is due to chronic gall bladder fibrosis impairing any enlargement in the case of gallstones.
• In reality, it is not a law ‘written in stone’ as historically suggested by some, it merely suggests that patients with jaundice secondary to cholelithiasis are less likely to have a palpable gall bladder, in comparison to those who are jaundiced secondary to other pathology.

• Two locations for percussion are used in the determination of splenomegaly: a) Castell’s point, which is the most important, and b) Traube’s space.
• - Under normal circumstances the spleen will lie proximal to both of these areas in both expiration and inspiration. If dullness is present in either position with inspiration or expiration, then splenic enlargement is likely.
• #
• Castell’s point: the junction of the anterior axillary line and the left subcostal margin. Percussion over the point is performed (preferably with an empty stomach) in both expiration and inspiration. Normally tympanic, a dull note in either state suggests splenic enlargement.
• 
• Traube’s space: is a triangular area bordered laterally by the anterior axillary line, the 6th rib superiorly and the costal margin. This area is a common site for splenic enlargement.
• - In the absence of an enlarged spleen, the area overlies the air-filled stomach and is therefore tympanic. With splenic enlargement the spleen moves in front of the stomach
• and the area becomes dull. Dullness in either inspiration or expiration suggests splenic enlargement.
• 
• Percussion is thought to be more sensitive than palpation for detection of enlargement of the spleen and is moderately good at detecting splenomegaly (sensitivity 60-80%, specificity 72-94%).
• Dullness at Castell’s point or Traube’s area does not always represent splenomegaly however, and alternative causes such as a large pericardial effusion or cardiomegaly may need to be considered. Tympany at Castell’s point or Traube’s space makes splenomegaly highly unlikely.

• Rebound or preferably percussion tenderness:
• Rovsing’s sign: Pain in the right lower quadrant with palpation of the left lower quadrant is a positive Rovsing’s sign and suggests appendicitis.
• Psoas sign: Place your hand over the patient’s right knee and ask them to raise their thigh against your hand. Flexing the hip will make the psoas muscle contract. An increase in the
• pain is a positive psoas sign and suggests irritation of the psoas muscle by an inflamed appendix.
• - The reverse psoas manoeuvre is carried out by asking the patient to roll onto their left side and hyperextend the right hip. A positive test is one that elicits pain. The psoas tests have low sensitivity, but high specificity.
• McBurney’s sign: is the presence of pain at McBurney’s point, which is two inches (he was American) medial to the anterior superior iliac spine on a line from the anterior superior iliac spine to the umbilicus.
• - Tenderness is noted to both direct and rebound palpation (specificity 75-85%).
• Valsalva manoeuvre: If the site of abdominal pain is poorly localised, ask the patient to strain and ‘bear down’ - this may help to identify the exact site of pain.
• Obturator test: Flex the hip by pushing the patient’s ankle towards the pelvis while pushing the knee medially so a to internally rotate the hip. Both legs should be tested.
• - The production of pain indicates inflammation of an organ surrounding the obturator internus muscle. Although specific for retrocaecal appendicitis, it is poorly sensitive.

• Where bowel goes into a place it shouldn't be
• Some hernias are irreducible, meaning cannot be pushed back into the abdominal cavity. Some irreducible hernias contain bowel, which may become obstructed, giving rise to symptoms of small bowel obstruction in addition to the irreducible lump.
• 
• Sometimes the bowel contents’ blood supply becomes jeopardised, and these are known as strangulated hernias; they are usually painful, red, tense and tender.

• 
• The principal sign of a hernia is a lump in the groin region. A lump that is present on standing, appears following a manoeuvre that raises intra-abdominal pressure and disappears on lying down is easily identified as a hernia.
• Indirect herniation: where bowel herniation occurs through a deficiency in the abdominal wall through the internal ring.
• - If the hernia is large, the hernia may pass through the external ring into the scrotum.
• 
• Direct inguinal hernia: is due to a weakness in the abdominal wall in the region of the external ring (Hesselbach’s triangle bounded inferiorly by the inguinal ligament, laterally by the inferior epigastric vessels and medially by the lateral border of the rectus sheath).
• - The bowel can herniate through the wall and bulge forwards through the external ring, but rarely passes into the scrotum.
• #
• Indirect inguinal hernias are by far the most common groin hernia.

• The femoral canal lies inferior to the inguinal ligament, below and lateral to the pubic tubercle, and medial to the femoral pulse.
• It is normally plugged with fat and a lymph node (Rosenmuller-Cloquet’s gland), but is a potential pathway for a direct femoral hernia.
• 
• A femoral hernia bulges through the femoral ring into the femoral canal. Femoral hernias bulge into the groin crease at its medial end. The lump is found lateral to the public tubercle, below the inguinal ligament (remember, femoral = lateral and below).

• Nystagmus is a disorder of eye fixation. The underlying abnormality in nystagmus is a slow drift of the eyes away from steady fixation.
• In “jerk nystagmus”, these slow movements are followed by rapid corrective eye movements. Vision is affected during the slow phase. This can cause either blurring or a perception of image movement, termed oscillopsia. There is no oscillopsia during the fast corrective movements.
• #
• Jerk nystagmus is named for direction of the quick phases, as well as the eye positions when it occurs. For example, “left beat nystagmus” is where the fast corrective movements are to the left, and “right beat nystagmus” is when the quick movements are to the right.
• #
• With respect to eye positions, if nystagmus is seen only when the eyes look to one side (e.g. right), this is called “first degree nystagmus”. If there is also nystagmus present in the primary position (eyes straight ahead), it is then called “second degree”. If there is nystagmus when the eyes look right, left and in the primary position, this is then called ”third degree nystagmus”.
• #
• Alexander’s Law states that nystagmus is most severe with gaze in the direction of the quick phases. Gaze evoked nystagmus occurs when the eyes are moved away from the primary position. If this “eccentric” position is maintained, the nystagmus amplitude may reduce.
• When the eyes are returned to the primary position, a brief nystagmus beating in the opposite direction - rebound nystagmus - may occur.
• Alcohol, sedatives and anticonvulsant intoxication are the most common causes, and it is a typical feature of cerebellar disease.

CN I – Olfactory;

• CN II – Optic;
• - Visual fields; Compare during confrontation with your own fields
• - Pupils; Assess responses to the “swinging flashlight test”
• CN III – Oculomotor
• - also tests IV and VI; check ptosis and eye movements
• 
• - III palsy: Ptosis, eye down and out, +/− dilated pupil. May cause both vertical and horizontal diplopia.
• - IV palsy: Vertical diplopia (often noticed on descending stairs). Tilting the head toward the affected side aggravates the diplopia; many patients compensate by tilting their head away from the side of the lesion.
• - VI nerve palsy: Esotropia (inward deviation) and an inability to abduct the affected eye. Patient complains of horizontal diplopia on looking out at a distance.
• CN IV – Trochlear
• CN V (1,2,3) – Trigeminal
• - Motor palsy: “ Open your mouth”: Jaw deviates to side of lesion.
• - Sensory: Corneal reflex lost first; check light touch in all three divisions on the face.
• CN VI – Abducens
• CN VII – Facial
• - Facial nerve lesions cause facial asymmetry (droop) and weakness of ipsilateral facial movements (except for lid movements). As the forehead has bilateral representation in the brain, only the lower two-thirds is affected in UMN lesions, but all of one side of the face in LMN lesions.
• - Ask patient to “raise your eyebrows” and “show me your teeth.”
• CN VIII – Vestibulocochlear
• - rub fingers together plus Weber and Rinne
• CN IX – Glossopharyngeal
• CN X – Vagus
• - Ipsilateral palate elevation (IX and X): Ask the patient to say “aaah” and observe whether the two sides of the palate move fully and symmetrically.
• - Can also use a swab to assess pharyngeal sensation and gag reflex, although the gag reflex is often absent in normal persons, especially the elderly.
• CN XI – Accessory
• - Trapezius: “ Shrug your shoulders” against resistance.
• - Sternocleidomastoid: “ Turn your head to the left/right” against resistance.
• CN XII – Hypoglossal
• - Tongue protrusion: Deviates to the side of the lesion.

• 
• Motor palsy: “ Open your mouth”: Jaw deviates to side of lesion.
• Sensory: Corneal reflex lost first; check light touch in all three divisions on the face.

• The Weber test: Conductive vs. sensorineural hearing loss
• - Strike the fork lightly so as to avoid overtones.
• - Hold its base on the patient’s forehead in the midline.
• - Ask the patient in which ear they hear the sound loudest.
• If there is sensori-neural deafness (i.e. there is a lesion affecting the perceptive mechanism – the cochlear or its innervation), bone conduction is decreased on that side and the sound is heard loudest in the normal ear.
• In there is a conductive hearing loss (i.e. there is a lesion of the sound amplification mechanism), the sound is heard loudest and longest in the affected ear – possibly because of the effect of ambient noise ‘masking’ the acuity of the normal ear.
• #
• Rinne test
• - Strike the fork lightly so as to avoid overtones.
• - Hold its base on the patient’s mastoid.
• - Measure the time taken until the sound is no longer heard, then immediately hold the prongs of the fork close to the ear canal.
• In normal people, air conduction is better heard than bone conduction (AC>BC) owing to the amplification by the tympanic membrane and ossicles.
• In sensori-neural deafness both are reduced with air still better than bone conduction (AC>BC) because of the aforementioned amplification.
• If air conduction is greater than bone conduction (AC>BC), this is termed a ‘positive’ Rinne result. If bone conduction is greater than air conduction (BC>AC), this is called a ‘negative’ Rinne.
• In moderate or severe conductive hearing loss, bone conduction is greater than air conduction (BC>AC), a ’negative’ Rinne.
• #
• False negative Rinne tests may occur in severe unilateral sensori-neural hearing loss. The bone conduction may appear better than air conduction because the sound is conducted from the mastoid through bone to the other ear. A ‘masking’ sound in the other ear may help prevent this potentially misleading result.

• Biceps, Supinator: C5–6
• Triceps: C7
• Finger flexor: C8
• Knee jerk: L3–4
• Ankle jerk: S1

• Joint position sense and vibration: toe and finger up or down?
• Vibration sense: If diminished check again proximal.
• # Co-ordination and cerebellar disease;
• The Romberg test: Ask the patient to stand with feet together and eyes closed. Stand with arms almost encircling the patient, ready to catch them, should they begin to topple.
• - This test is intended to detect unsteadiness from position sense loss, but can also be abnormal in cerebellar disease, or in an acute vestibular lesion.
• Finger nose test: Instruct the patient to touch your finger, then their nose, then your finger again.
• - If the ataxia is severe, the patient should touch their shoulder to avoid striking their face. There may be tremor accentuated as the target is approached, and clumsiness during the whole of the movement.
• Heel shin test: Ask the patient to run the heel smoothly and quickly, but not carelessly, down the anterior tibia.
• Dysdiadochokinesia tests: Ask the patient to tap the back of one hand alternately with the palmar and then dorsal surfaces of the finger tips of the other.