Veins: Neck Veins

To assess central venous pressure and right atrial hemodynamics

Method Of Exam

Author: A. Chandrasekhar Consultant: R. Lichtenberg

and R. Gunnar

Inspect for internal jugular vein pulsations in the neck, in supine position and with neck and trunk raised
to approximate angle of 45o. Internal jugular vein pulsation are visible at the root of the neck between
clavicular and sternal heads of sternoclidomastoid muscle. Internal jugular vein corresponds to a line drawn
from this point to infra auricular region.
Inspection with simultaneous palpation of the carotid and/or auscultation of the heart will assist in
identification and timing of the waves.
Inspect the vein from different angles. Apply light tangentially and observe for venous pulsations in the
shadow of neck on the pillow.

At 0o jugular veins should be filled. An impulse visible just prior to S1 or the upstroke of the carotid is the
"a-wave". This will be followed by a x-descent. The 'c' wave is usually not visible. The 'v' wave occurs
after the start of the carotid upstroke and during ventricular systole (which is atrial diastole). When the
tricuspid valve opens there is a brisk descent (y-descent).

Observe the venous pressure changes with respiration. There is normally a drop in intrathoracic pressure
with inspiration. This decrease is also reflected on the intracardiac pressures. Therefore, an increase in the
pressure difference between the SVC/IVC and the RA increases cardiac filling.

Normal:
Neck veins are not visible at 45 o inclination.
Neck veins should be visible in supine position.
JVP should decrease with inspiration.
 Abnormal Finding

Neck vein distension at 45 o inclination is abnormal and is indicative of increased central venous pressure.
Describe the level to where the pulsations are seen in relationship to the angle of Louis. Note the effect of
inspiration. Apply gentle pressure to right upper quadrant and note its effect on neck veins (hepatojugular
reflux). If neck vein distension is present identify a, c and v waves and describe their amplitude.

 Distended pulsatile neck veins ( CHF, Tricuspid insufficiency)

 Hepatojugular reflux: Right ventricular non-compliance to increased filling
 Distended non- pulsatile neck veins: ( SVC syndrome , cardiac tamponade, Constrictive
pericarditis). These patients usually have prominent descents.
 Quick Y descent and X descent: (Constrictive pericarditis)
 Distended veins during expiration only: (COPD, Asthma)
 Prominent "a" wave: "a" waves are due to atrial contraction and when abnormally prominent
indicate atrial contraction into a noncompliant right ventricle or through a stenotic or closed
tricuspid valve. In complete heart block and with premature ventricular contraction there is loss of
a-v synchrony. When the atrial and ventricular contractions coincide a prominent wave is seen.
This is called cannon a-wave. A noncompliant right ventricle can be hypertrophied (secondary to
pulmonary hypertension) or "stiff" due to scar (ischemia/infarct) or infiltrative disease (amyloid).
 JVP which increase with inspiration indicate restricted filling of the right sided chambers
(Kussmaul's signs).
 Absent "a" waves: (Atrial fibrillation).
 "v" waves are most commonly due to an insufficient tricuspid valve with the ventricular systolic
pressure reflected in the atrium during atrial filling (diastole).
 Prominent "v" wave: (Tricuspid regurgitation).
 Cannon wave: (Heart block, Premature ventricular contraction).
 Knowledge Base

 Anatomy of neck veins

o Internal jugular vein
 Deep behind sternoclidomastoid muscle
 From the angle between sternal and clavicular head of sternomastoid to angle of
neck
o External jugular vein
 Clinical methods for estimation of central venous pressure.
 Physiology of a, c, v waves.
o a: atrial contracion
o v: venous filling
o x descent: atrial relaxation
o y descent venous emtying
o c: not easily visible
 Effect of respiration and pleural negative pressure on atrial filling.
o Increased intrathoracic negative pressure facilitates venous return and filling of atrium
o Hence neck veins decrease in height during inspiration
 Conditions causing venous distension and prominent a or c or v waves.
 Anatomical relationship to neck muscles and carotid artery.
 Hepatojugular reflux.
Resources: Bates, A Guide to Physical Exam.

Arterial Pulse: Radial

To assess cardiac function. To assess state of health.

Method Of Exam

Author: A. Chandrasekhar Consultant: R Gunnar

and R. Lichtenberg
 Simultaneously palpate both radial pulses.
 Note the rate, rhythm, character, amplitude and compare both pulses.
 Feel the pulse with one finger.
 To evaluate character of pulse - compress brachial artery against humerus and let up part way
to feel percussion and tidal peaks.
 Raise the patient's forearm and feel for a bounding pulse by feeling with the flat of your palm.

Normal:

 Pulse is symmetrical, regular and between 60-90 per minute.

 You have to learn to appreciate the character and amplitude of the normal pulse
 Abnormal Finding

 Rate
o Bradycardia: Less than 60/min (Myxedema, heart block, raised IC
tension, obstructive jaundice)
o Tachycardia: Faster than 100/min. (Sinus tachycardia, PAT, atrial
flutter, ventricular tach)
 Rhythm
o Irregular: (Sinus arrhythmia, extra systoles, atrial fib, pulses bigemini)
o Alternating weak and strong pulse:
 Pulses bigemini: Normal beat alternating with extra systole
(Dig toxicity)
 Pulses alternans: Normal beat alternating with low amplitude
beat
 Amplitude
o Slow small sustained (Aortic stenosis)
o Large bounding pulse: Water hammer pulse: (Aortic insufficiency,
high output states, slow heart rates)
o Double systolic peak: Bisferiens pulse (Aortic regurgitation)
o Decrease in amplitude during inspiration: Paradoxical pulse
Exaggerated in (Pericardiac tamponade, obstructive lung disease)
 Compare
o Missing or feeble on one side: (Prior cath, Takayasu's disease,
subclavian steel syndrome)
 Grading Pulse
o 4=Normal
o 3=Slightly diminished
o 2=About half
o 1=Barely palpable
o 0=Absent

Knowledge Base

 Surface anatomy of radial and brachial artery

 Physiology of pulse
 Diseases altering pulse characteristics
 Cardiac arrhythmias

Resources: Bates, A Guide to Physical Exam

Blood Pressure
To evaluate one of the vital signs

Method Of Exam

Author: A. Chandrasekhar

Select an appropriate size cuff .The bladder in the cuff should encircle at least half of the arm. You have to
use a larger cuff in obese patients. Identify systolic blood pressure by palpatory method.

 Palpatory method:
 o Empty air from the cuff and apply the cuff firmly around the patient's arm.
o Feel the radial pulse.
o Inflate the cuff until the radial pulse disappears.
o Inflate 30-40 mm over and release slowly until the pulse returns. That denotes systolic
pressure.
o Diastolic blood pressure cannot be obtained by this method.
o Identification of systolic blood pressure by palpatory method helps one to avoid a lower
systolic reading by auscultatory method if there is an auscultatory gap.
o It also minimizes the discomfort of over inflating the bladder of the cuff.
 Auscultatory method:
o Keep the bell of stethoscope over the brachial artery and inflate blood pressure cuff to a
level higher than the systolic pressure determined by the palpatory method. Steadily
deflate.
o Record systolic and diastolic pressures based on the Korotkoff sounds.

Record blood pressure in both arms, in supine and in standing position in the first clinical visit For
subsequent evaluation use the arm with a higher reading. You need to evaluate supine and standing BP if
there is suspicion for Orthostatic hypotension

If obstruction to vessels of lower trunk and limbs (coarctation of aorta, Lerich syndrome) is suspected
measure BP in legs.

 Apply the cuff around thigh and place the stethoscope in popleteal fossa to listen to Korotkoff
sounds.
 You may have to use a larger cuff for legs.
 Abnormal Finding

Abnormal Finding

 Hypertension:
o Two or more diastolic pressures 90 or over on subsequent visits
o 40% of older patients
 Systolic hypertension:
o Systolic greater than 160 with diastolic less than 90
o Systolic blood pressure rises linearly with age.
o Isolated systolic hypertension in 10-20% or more of 65+ years old.
 Hypotension: Less than 90/60, or a value based on past reading and current
clinical state
 Postural hypotension: Fall of 20 mm Hg of systolic pressure in erect
position (Drugs, volume loss, autonomic dysfunction)
 Differential hypertension: Lower BP in legs (Coarctation of aorta)
  Asymmetric BP: Difference between arms more than 15 mm of Hg
(Subclavian steal, dissection of thoracic aorta)

Knowledge Base

 Physiology of blood pressure

o LV stroke volume
o Distensibility of vessels
o Peripheral vascular resistance
o Blood volume
 Korotkoff sounds
o Initial appearance of sounds marks systolic pressure
o Muffling and disappearance of sounds marks diastolic pressure
 Auscultatory gap
 Cuff size requirements
o Cuff width 40% of the circumference of the upper arm.
o Length of the bladder 80% of the circumference of the upper arm.
o Longer and larger cuff for legs
o Cuffs too short or too narrow may give false high reading
 Diseases altering blood pressure

Resources: Bates, A Guide to Physical Exam.

Pulse: Carotid Arteries: Palpation

To determine patency of carotid artery. To assess dynamics of the left
ventricle and aortic valve.

Method Of Exam

Author: A. Chandrasekhar Consultant: F. Littooy

 Palpate one side at a time.
 Gently tilt the head to relax the sternomastoid muscle.
 Palpate the carotid artery by placing your fingers near the upper neck between the sternomastoid
and trachea roughly at the level of cricoid cartilage..
 Repeat the procedure on the opposite side.
 Palpate simultaneously carotid artery and apical impulse and note the timing between them.

Caution:

 Avoid compression of carotid sinus which is located at the level of the top of thyroid cartilage.
 Avoid simultaneous palpation of both carotid arteries.

Normal: Carotid artery pulsations are symmetrical and have similar characteristics as the radial artery.

Abnormal Finding

 Increased:
 o Pulsatile bulge: (Tortuous and kinked, Aneurysm)
o Hyper dynamic stroke: (High output state).
 Absent or decreased pulse on one side: (Proximal carotid, Innominate
stenosis or Occlusion)
 Systolic thrill : ( Carotid stenosis)
 Delay compared to apex: ( Aortic stenosis)

Knowledge Base

 Anatomy of carotid artery and its relationship to neck muscles

 Effect of compression of carotid artery
o Supplies brain with collateral supply from opposite carotid artery and
vertebral vessels
 Anatomy of carotid sinus and effect of pressure
o Carotid sinus at the level of thyroid cartilage
o Vaso-vagal syncope can be induced by massaging carotid sinus
 Disease causing obstruction and dilatation
 Pathology

Pulse: Carotid Arteries: Auscultation

To listen for bruits caused by carotid stenosis or from flow disturbances
transmitted from the aortic valve or subclavian artery.

Method Of Exam

Author: A. Chandrasekhar Consultant: H. Griesler

and F. Littooy
 Auscultate the carotid arteries with diaphragm and then with bell.
 It is important to listen to at least three locations over each carotid artery: 1) the base of neck; 2)
the carotid bifurcation; and, 3) the angle of the jaw.
 Listen also over the subclavian artery.

Normal: A pulse is normally heard, but without sounds during systole

 Abnormal Finding

If bruit is heard, note whether it is systolic or continuous.

Examine in the upright and supine position.

Auscultate over the aortic and subclavian area to determine whether the bruit is
transmitted or originates in the carotid artery.

 Carotid bruit: (Carotid artery stenosis)

 Transmitted murmur: (Aortic stenosis, Subclavian artery stenosis, Arch
branch stenosis)
 Venous hum: Continuous thrill and murmur at the root of the neck in sitting
position disappearing in supine position and compression. Hyper dynamic
state
o Anemia
o Thyrotoxicosis
o Pregnancy

Knowledge Base

 Anatomy of carotid artery and its relation to sternomastoid

 Significance of murmurs
o Due to increased velocity of the flow past a stenosis
o Not always indicative of stenosis of underlying vessel
 Concept of radiation of murmurs
 Pathology of vascular stenosis

Respiratory Rate and Pattern of Breathing

To evaluate one of the vital signs

Method Of Exam

Author: A. Chandrasekhar

 The patient should not be aware that you are counting his respiratory rate. Count the respiratory
rate while pretending to take the patient's pulse.
 Note the rate, pattern and comfort of respiration.

Normal:

 Resting rate is between 10-14 per minute, regular with no apparent discomfort..
 Chest wall and abdomen expand during inspiration and is symmetrical.
  Abdominal component of expansion is dominant in men and thoracic component in women.
 Periodic deep breathing (Sighs) less tha 5 per minute.

Abnormal Finding

Minor changes in rate and rhythm of respiration occur due to anxiety and while it may represent an
abnormality, it may not be significant.

 Rate
o Rate below 10/min: Bradypnea: (Narcotics, raised intracranial tension, myxedema)
o Rate above 20/min: Tachypnea: (Interstitial, vascular and multitude of diseases, anxiety)
 Pattern
o Periodic breathing. Cyclical increase and decrease in depth of respiration: Cheyne-stokes
breathing: (CHF, Cerebrovascular insufficiency)
o Slow deep breathing: Kussmaul: (Ketoacidosis)
o Totally irregular with no pattern:Biot's breathing: (CNS injury)
o Periodic deep breathing: Sighs: (Anxiety state)
o Instead of simultaneous chest and abdominal expansion with inspiration abdomen retracts
while chest expands: Abdominal paradox: (Diaphragmatic paralysis)
o On the side of unstable chest wall hemithorax retracts while the normal side expands with
inspiration: Thoracic paradox: (Flail chest)
o With lips pursed patient controls expiration slowly: Pursed lip breathing: (Obstructive
lung disease)
o No abdominal component : ( Acute abdomen)
o No thoracic component: (Pleurisy, Chest wall pain, Ankylosing spondylitis)
 Discomfort
o Labored breathing: (Heart and Lung diseases)
o Unable to assume supine position because of worsening shortness of breath: Orthopnea:
(CHF, Diaphragmatic paralysis, SVC syndrome, Anterior mediastinal mass)
o Unable to erect position because of worsening shortness of breath, more comfortable in
supine position : Platypnea: (Pulmonary spiders in cirrhotic)

Knowledge Base

Physiology of respiration

Abnormal patterns of respiration

Diseases causing abnormal patterns of respiration

Compensatory mechanisms for abnormal respiration

Trachea: Position
To evaluate the position of the upper mediastinum.

Method Of Exam

Author: A. Chandrasekhar
1. Position yourself in front of the patient and note the position of the thyroid cartilage.
2. Inspect for the symmetry of clavicular insertion of both sternomastoids.
 3. Tracheal Position: Gently bend the head to relax the sternomastoids. By inserting your finger
between the trachea and sternomastoid, assess and compare the space on either side.

Caution:

Make certain that the patient is seated straight or preferably standing erect.

Normal: Trachea is slightly tilted to right. As a result, the clavicular insertion of right Sternomastoid is
slightly more prominent and the space between trachea and sternomastoid is smaller compared to left.

Abnormal Finding

Tracheal deviation could be either due to Lung, pleural, Mediastinal or Chest wall disease. The
mediastinum can be either pulled or pushed away from the lesion.

 Lung
o Pull: ( Loss of lung volume)
 Atelectasis
 Fibrosis
 Agenesis
 Surgical resection
o Push: (Space occupying lesions)
 Large mass lesions
 Pleura
o Push:
 Pneumothorax
 Pleural effusion
o Pull:
 Pleural fibrosis
 Mediastinal masses and thyroid tumors
 Kypho-scoliosis
Note prominent right sternomastoid indicating a shift of trachea to the right. Patient
had right lower lobe resected in the past.
 Resorptive atelectasis

When airways are obstructed there is no further

ventilation to the lungs and beyond. In the early stages
blood flow continues and gradually the oxygen and
Nitrogen get absorbed, resulting in atelectasis.

The following in an example of right lung resorptive

atelectasis. In this instance, atelectasis followed
bronchial obstruction due to cancer.
Note the shift of mediastinum to left.
 Knowledge Base

Anatomy of Sternomastoid muscles

Know what is mediastinum.

Anatomy of Trachea

 Slants slightly to right

 Bifurcates at the level of sternal angle anteriorly and fourth thoracic spinous process posteriorly

Location and direction of tracheal slant

Anatomy of Thyroid gland

Physiology of pleural dynamics with respiration

Disease causing shift of Trachea

Pathology of atelectasis, pleural effusion, mass, pneumothorax

Chest: Observation
To evaluate chest wall and symmetry of hemithorax . To assess negative
pressure in the pleural space.

Method Of Exam

Author: A. Chandrasekhar
 Stand either at foot end or by the head end and observe the symmetry of hemithorax.
Inspect the chest all around with the patient in sitting position.
 Observe the intercostal space, supraclavicular fossa and tracheal movement during quiet
respiration.
 Examine the skin and soft tissue.

Abnormal Finding

 Chest asymmetry
o Kyphoscoliosis
o Larger hemithorax : (Pneumothorax, Pleural effusion)
o Smaller hemithorax: (Atelectasis, Pleural fibrosis, Agenesis of Lung)
 Increased pleural negative pressure: Unilateral (airway obstruction) or bilateral (COPD, DIF,
Asthma)
o Intercostal and supraclavicular fossa retraction
o Downward movement of trachea with quiet inspiration
 Skin and soft tissue
o Puncture sites and Scars (Thoracentesis, FNAB, Chest tube, Surgical scars)
o Prominent collateral veins (SVC syndrome)
o Swelling (Recent thoracentesis, Empyema, Mesothelioma, Empyema necessitatis, Cystic
hygroma, Actinomycosis)
o Erythema (Empyema)
o Warmth (Empyema)
o Tenderness ( Empyema, Rib and chest wall lesions )
o Subcutaneous nodules (Metastasis)
 Knowledge Base

Anatomy of thorax and chest wall

Physiology of chest expansion and pleural pressures

Diseases altering size and symmetry of thorax

 Mesothelioma
 Emphysema
 Pleural effusion
 Pneumothorax

Signs of increased negative pleural pressures

Ref: Review Dr.Webber's pulmonary lessons on "Function".

 Chest Expansion
To assess overall chest expansion with inspiration. To identify the side of
abnormality.

Method Of Exam

Author: A. Chandrasekhar

 Overall chest expansion: Take a tape and encircle chest around the level of nipple. Take
measurements at the end of deep inspiration and expiration.
 Symmetry of chest expansion:
o Have patient seated erect or stand with arms on the side. Stand behind patient. Grab the
lower hemithorax on either side of axilla and gently bring your thumbs to the midline.
Have patient slowly take a deep breath and expire. Watch the symmetry of movement of
the hemithorax. Simultaneously, feel the chest expansion.
 o Place your hands over upper chest and apex and repeat the process.
o Next, stand in front and lay your hands over both apices of the lung and anterior chest
and assess chest expansion.

Normal:

 Normally, a 2-5" of chest expansion can be observed.

 Chest expansion is symmetrical.

Abnormal Finding

 Decreased overall chest expansion

o Diffuse lung and Pleural disease(Emphysema, DIF)
o Stiff thorax (Ankylosing spondylitis)
o Diaphragmatic paralysis

Any lung or pleural disease can give rise to a decrease in overall chest expansion. It is typically
low in patients with COPD. These patients have a very high FRC and have limited capability to
expand the chest from this position.

 Asymmetric chest expansion

o Kyphoscoliosis
o Unilateral loss of lung volume (Atelectasis, Resection, Pleural fibrosis)
o Unilateral space occupying lesions (pneumothorax, pleural effusion, Large mass)

Asymmetrical chest expansion is abnormal. The abnormal side expands less and lags behind the
normal side. Any form of unilateral lung or pleural disease can cause asymmetry of chest
expansion.

Knowledege Base

Anatomy of chest wall and diaphragm.

Physiology of movements of chest with respiration Physiology of diaphragmatic motion

Surface anatomy of lobes of lungs

Pathology of emphysema Ventilation and lung lesions

 Voice transmission
Method Of Exam

Author: A. Chandrasekhar

 Patient to say "99" "1, 2, 3" or "E"

 Each time you lay your hands or listen
 All around the chest and compare
 Dorsal surface of your fingers or ulnar surface of your hand (tactile fremitus)
 Listen with diaphragm (vocal resonance)
 If increased have patient whisper

 Note the intensity

 Quality of pitch
  Compare

Abnormal Finding

 Decreased: (Pleural effusion, Pneumothorax, Atelectasis, Mass)

 Increased: (conditions giving bronchial breathing)
o Bronchophony: (Normal)
o Whispering pectoroliquy ( Normal )
 Qualitative: Egophony

Knowledge Base

Sound transmission
Voice transmission

Lungs: Percussion
To assess the amount of air in lung. To assess movement of the diaphragm.

Method Of Exam

Author: A. Chandrasekhar

 Percuss the lung fields, alternating, from top to bottom and comparing sides.
 Percuss over the intercostal space and note the resonance and the feel of percussion.
 Keep the middle finger firmly over the chest wall along intercostal space and tap chest over distal
interphalangeal joint with middle finger of the opposite hand.
 The movement of tapping should come from the wrist.
 Tap 2-3 times in a row.
 Do not leave the percussing finger on chest , otherwise you will dampen the sound.
 Stand on one side and with your flat of hand, tap the chest from top to bottom and from side to
side to compare. I use this method as a screening step to identify the area of abnormality.

Percuss the chest all around. Stand back, have the patient cross arms to shoulder. This maneuver will wing
the scapula and expose the posterior thorax. Then, have the patient keep their hands over head and percuss
axilla. Then move to the front and percuss anterior chest , clavicles and supraclavicular space.

Movement of Diaphragm:

 Identify the lower limit of resonance during deep inspiration and deep expiration.
 This determines the range of movement of the diaphragm.

Normal:
The lung is filled with air (99% of lung is air). Hence, percussion of it gives a resonance. This step helps
identify areas of lung devoid of air.

 Appreciate the dullness of the left anterior chest due to heart and right lower chest due to liver.
 Note the hyper-resonance of the left lower anterior chest due to air filled stomach.
 Normally, the rest of the lung fields are resonant.
 Normal diaphragmatic excursion is 5-6 cm.
 Abnormal Finding

 Lungs fields
o Dullness: (Mass, Atelectasis, Consolidation, Pleural effusion)
o Hyper-resonance: (Emphysema, Asthma, Pneumothorax, Blebs)

Decreased or increased resonance is abnormal. Increased resonances can be noted either due to
lung distention as seen in asthma, emphysema, bullous disease or due to Pneumothorax.
Decreased resonance is noted with pleural effusion and all other lung diseases. Experienced
physicians are able to discriminate between dullness of pleural effusion from a consolidation or a
mass lesion of lung. The dullness is flat and the finger is painful to percussion with pleural
effusion.

 Diaphragmatic motion
 o Decreased diaphragmatic excursion: (Emphysema, paralysed diaphragm)

Knowledge Base

Surface anatomy of lobes of lungs

Relationship of Lungs to Liver, Heart and Stomach.

Relationship between ribs and intercostal space

Anatomy of diaphragm

Physiology of diaphragmatic motion

Pathology of effusion, pneumothorax, consolidation, emphysema

Ref:

1. Review Dr. John McNulty's lesson, "Overview lecture on Thorax".

Using a marking pen, start 3 centimeters above clavicle in midclavicular line, come down
along right parasternal line, join to 6th rib in midclavicular line, to 8th rib in mid-axillary
line, to 10th rib posteriorly, to vertebral line posteriorly.
 DIAPHRAGM

Origin
Vertebral:crura from bodies of
Action
L1, 2 (left), L1-3(right). Costal:
Inspiration and assists in
med and lat arcuate ligs, inner
raising intra-abdominal
aspect of lower six ribs . Sternal:
pressure
two slips from post aspect of
xiphoid
Nerve
Insertion Phrenic N (motor) (C3,
4, 5). Sensory: phrenic,
Trefoil central tendon intercostals(6-12) and
upper two lumbar N
roots
 Auscultation of Lungs
To assess air entry to the lung. To assess obstruction to airways.

Method Of Exam

Author: A. Chandrasekhar

 While the patient breathes normally with mouth open, auscultate the lungs, making sure to
auscultate the apices and middle and lower lung fields posteriorly, laterally and anteriorly.
 Alternate and compare sides.
 Use the diaphragm of the stethoscope. Listen to at least one complete respiratory cycle at each site.
 First listen with quiet respiration. If breath sounds are inaudible, then have him take deep breaths.
 First describe the breath sounds and then the adventitious sounds.
 Note the intensity of breath sounds and make a comparison with the opposite side.
 Assess length of inspiration and expiration. Listen for the pause between inspiration, expiration
and the quality of pitch of the sound
 Also compare the intensity of breath sounds between upper and lower chest in upright position.
Compare the intensity of breath sounds from dependent to top lung in the decubitus position.
 Note the presence or absence of adventitious sounds.

Normal:
There are two normal breath sounds. Bronchial and vesicular. Breath sounds heard over the
tracheobronchial tree are called bronchial breathing and breath sounds heard over the lung tissue are called
vesicular breathing. The only place where tracheobronchial trees are close to chest wall without
surrounding lung tissue are trachea, right sternoclavicular joints and posterior right interscapular space.
These are the sites where bronchial breathing can be normally heard. In all other places there is lung tissue
and vesicular breathing is heard.

The bronchial breath sounds over the trachea has a higher pitch, louder, inspiration and expiration are equal
and there is a pause between inspiration and expiration.
The vesicular breathing is heard over the thorax, lower pitched and softer than bronchial breathing.
Expiration is shorter and there is no pause between inspiration and expiration. The intensity of breath sound
is higher in bases in erect position and dependent lung in decubitus position.

The breath sounds are symmetrical and louder in intensity in bases compared to apices in erect position. No
adventitious sounds are heard.

Abnormal Finding

Intensity of breath sounds, in general, is a good index of ventilation of the underlying lung. If the
intensity increases there is more ventilation and vice versa. Breath sounds are markedly decreased in
emphysema.

Symmetry: If there is asymmetry in intensity, the side where there is decreased intensity is abnormal.
Any form of pleural of pulmonary disease can give rise to decreased intensity.

Bronchial breathing anywhere other than over the trachea, right clavicle or right interscapular space is
abnormal. Presence of bronchial breathing would suggest:

 Consolidation
 Cavitation
 Complete alveolar atelectasis with patent airways
 Mass interposed between chest wall and large airways
 Tension Pneumothorax
 Massive pleural effusion with complete atelectasis of lung

In all these conditions, there are no ventilation into alveoli and the sound that is heard originates from
bronchi and is transmitted to the chest wall.

Experienced physicians could discriminate between consolidation and cavitation by noting the quality of
bronchial breathing. In consolidation, the bronchial breathing is low pitched and sticky and is termed
tubular type of bronchial breathing. In cavitary disease, it is high pitched and hollow and is called
cavernous breathing. You can simulate this sound by blowing over an empty coke bottle. In tension
pneumothorax bronchial breath sounds has a metallic quality and is called amphoric breathing.

Adventitious sounds

 Wheeze
 Stridor
 Crackles
 Pleural Rub

Knowledge Base

 Physiology of breath sounds

 Surface anatomy of Tracheo-bronchial tree and lobes of lungs
o Bronchial breath sound over Trachea
o Vescicular breath sounds over lung fields
o Broncho-vesicular breath sounds in right interscapular and infraclavicular (medial end)
regions
 Ventilation and intensity of breath sounds
 Normal relationship between alveoli and bronchial tree
 Sound tranmission principles
 Mechanism of production of adventitious sounds
 Ventilation and gravity relationship
 Surface anatomy of tracheobronchial tree
 Pathology of consolidation, cavitation, pneumothorax, pleural effusion, emphysema, Mass, infarct,
asthma, and bronchiectasis.
 Abdomen Exam

Author: Arcot J. Chandrasekhar, MD, FRCP, FACP, FCCP

Abdomen: Observation

Method Of Exam

Author: A. Chandrasekhar Consultant: M. Klamut

and J. Pickleman
 The patient should be lying flat with arms at his side and relaxed. Observe for:
o Contour of the abdomen
o Skin and subcutaneous tissue
o Umbilicus
o Peristalsis and pulsations
 Stand on right side and view the abdomen tangentially to visualize peristalsis.

Normal:
 The contour of the abdomen can vary.
 The umbilicus is in mid-line.
 In thin individuals, the epigastric pulsation and occasional gentle peristalsis may be
visible.
 Abnormal Finding

 Contour:When protuberant note the distance between umbilicus to symphysis-pubis and

epigastrium. Observe the flanks. Percuss abdomen. If dull, and ascites is suspected elicit fluid
thrill and shifting dullness.
o Pregnancy: Umbilicus to symphysis pubis longer than umbilicus to xiphisternum. Foetal
heart tones. Dull to percussion.
o Ascites: Flanks full, dull to percussion, shifting dullness, fluid thrill.(Cirrhosis)
o Obesity:
o Flatus: Resonant to percussion.(Intestinal obstruction, Ileus)
o Tumor: Asymmetry (Large Liver or Spleen, Myelofibrosis with Hepatosplenomegaly,
Kidney, Pelvic organ tumors)
 Skin and subcutaneous tissue
o Scars: Location and type helps identify previous surgery.
o Striae: Stretch marks indicate previous distension of abdomen.. Pink purple striae seen in
Cushing's syndrome.
o Distended collateral veins: When seen identify the direction of flow both for the veins
above and below umbilicus. (Portal hypertension, Caput medusae, SVC and IVC
obstruction)
o Hernia
 Umbilical hernia:
 Incisional hernia:
 Linea alba hernia: Small, midline tender herniation usually in epigastrium.
 Diastasis recti: Midline ridge like bulge between rectus abdominis muscles.
 Umbilicus
o Eversion: Raised intra-abdominal pressure (Ascites, Tumor)
o Hernia: (Congenital, Raised intra-abdominal pressure)
o Deviation: (Ipsilateral paralysis of Rectus abdominis)
 Pulsation: Epigastric ( Aortic aneurysm)
 Visible peristalsis: Exaggerated (Intestinal obstruction)
o Prominent: ( Intestinal obstruction)
o Absent : (Peritonitis)
 Knowledge Base

Surface anatomy of abdominal structures

Size of normal organs

 Normal Kidney
 Normal Spleen

Effect of increased intra-abdominal pressure

Pathology of conditions causing increased intra-abdominal pressure

 Cystic Dysplastic Kidneys

 Cystic Dysplastic Kidneys/abdomen opened
 Cirrhosis

Venous collateral flow of abdominal wall

Peristalsis
 Abdomen: Auscultation
To judge the motility of bowels; patency of vessels in the abdomen;
presence of fetal heart sounds; and, smoothness of liver and splenic
surface.

Method Of Exam

Author: A. Chandrasekhar Consultant: J. Pickleman

 Note that the abdomen should be auscultated prior to palpation.
 Auscultate in all four quadrants of the abdomen.
 Auscultate for a minute before determining the absence of peristaltic sounds. Note the frequency
and character of bowel sounds.

Normal:

 Bowel sound consist of clicks and gurgles and 5-30 per minute.
 An occasional borborygmus (loud prolonged gurgle) may be heard.
 Abnormal Finding

 Bowel sounds
o Increased: (intestinal obstruction, Diarrhea)
o Decreased : (Peritonitis, Ileus)
 Aortic bruit: With both systolic and diastolic components (Narrowing of Aortic lumen)
 Renal bruit: Epigastric systolic and diastolic bruit and costovertebral angles (Renal artery
stenosis)
 Foetal heart
 Uterine shoufle
 Splenic friction rub: Grating sound corresponding to respiration (Splenic infarct)
 Hepatic friction rub: Grating sound corresponding to respiration (Malignancy, Perihepatitis, Post
biopsy)
 Hepatic bruit: (Hepatoma)
 Venous hum: Continuous humming noise due to collaterals (Portal hypertension)

Knowledge Base

Surface anatomy of liver, spleen, aorta and kidney

Normal conditions creating sound in abdomen.

 Peristalsis
 Pregnancy
o Uterine shuffle
o Fetal heart sounds

Pathology of lesions creating sound in abdomen.

 Aortic aneurysm and atheromatous changes

 Splenic infarct in leukemia
Abdomen: Superficial Palpation
To evaluate the abdominal wall and intra-abdominal contents

Method Of Exam

Author: A. Chandrasekhar Consultant: J. Pickleman

and M. Klamut

Warm up your hands by rubbing them against each other. Prior to starting, ask the patient whether there are
any painful areas in the abdomen. After you have inquired about tender areas, this is the last of the four
quadrants which should be palpated. Never palpate the tender area first. Gently palpate all four
quadrants starting from the right lower quadrant.

 Evaluate the subcutaneous tissue and rectus muscle tone.

Normal: Abdomen is soft, rectus muscle is relaxed and no discomfort is elicited during palpation.

Abnormal Finding

 Subcutaneous nodules ( Metastasis)

 Rigidity guarding (Peritonitis)
 Tenderness

Knowledge Base

Anatomy of intra-abdominal organs

Direction of enlargement of organs

 Liver: Enlarges towards right lower quadrant

 Spleen: Diagonally towards right lower quadrant

Anatomy of abdominal wall

Pathology of peritonitis

Ref:

1. Review Dr. John McNulty's lesson, "Human cross sections".

 Abdomen: Deep Palpation
To evaluate abdominal mass structures.

Method Of Exam

Author: A. Chandrasekhar Consultant: J. Pickleman

and M. Klamut
 The two handed method may be used. Begin at the right lower quadrant and examine the entire
abdomen gently by deep palpation.
 Lay one hand over the abdomen and push with the second concentrating on the feel of the bottom
hand. Once again, known tender areas should be palpated last.

Normal:

 Normal pulsations of the aorta are recognizable in patients with a thin abdomen.
 Note that if the colon is filled with feces, you can leave an indentation by gentle pressure.

Abnormal Finding

If a mass is palpable describe its location, size, shape, consistency, tenderness, pulsation and mobility.

 Abdominal mass (Pseudocyst pancreas, Appendicitis, Diverticulitis etc)

 Retroperitoneal mass (Cancer Kidney)
 Aortic aneurysm

 If pulsation is noted determine whether it is transmitted or non-transmitted by examining the mass

in knee chest position.
 If there is tenderness evaluate for peritoneal irritation by eliciting rebound tenderness. Press
your fingers gently and slowly and quickly withdraw. If there is peritoneal inflammation
withdrawal of pressure causes pain.
 Organomegaly (Liver, Spleen, Uterus)

Knowledge Base
Anatomy of intra-abdominal organs

Direction of enlargement of organs

 Liver: Enlarges towards right lower quadrant

 Spleen: Diagonally towards right lower quadrant

Anatomy of abdominal wall

Pathology of peritonitis

Liver: Palpation
To assess liver enlargement.

Method Of Exam

Author: A. Chandrasekhar Consultant: J. Pickleman

 and M. Klamut
 Place your right hand on the patient's abdomen in the right lower quadrant. Gently move up to
the right upper quadrant lateral to the rectus muscle. Gently pressing in and up, ask the patient to
take a deep breath.
 If the liver is enlarged, it will come downward to meet your fingertips and will be recognizable.

Normal:

In normal patients, the edge of the liver may be palpable just below the costal margin. It is soft and smooth
and may be slightly tender.

Caution:

You should try to palpate liver by superficial palpation and not deep palpation. Liver edge is just hugging
anterior abdominal wall. With superficial palpation, let the liver edge come and touch your fingers with
deep breathing rather than you going after liver.

Abnormal Finding

If the Liver is enlarged describe how many fingers wide below costal margin, consistency, surface and
tenderness.

 Malignancy: Hard with irregular surface.

 Cirrhosis: Firm with smooth or irregular surface
 Fatty Liver: Soft smooth surface
 Congestive heart failure: Soft to firm, smooth surface with tenderness.
 Hepatitis: Soft and tender.
 Sarcoidosis and many other systemic diseases

Knowledge Base

Anatomy of liver relationships: (autopsy, drawing)

  Liver span 8-10 cm in mid-clavicular line
 Palpable Livers are not always abnormal (Can be displaced down)

Surface anatomy of liver.

Physiology of diaphragmatic motion and its effect on liver

Diaphragmatic position and its effect on liver position.

Pathology of lesions causing liver enlargement

 Malignancy: Hepatoblastoma (Cut surface)

 Metastatic: Carcinoid (Cut surface)
 Cirrhosis
 Hepatitis
 Sarcoidosis
 Fatty Liver
 Nutmeg Liver
Liver: Percussion
To quantitate the size of the liver

Method Of Exam

Author: A. Chandrasekhar Consultant: J. Pickleman

and M. Klamut
 Starting at a level below the umbilicus in the right mid-clavicular line, lightly percuss upward
toward the liver. Ascertain the lower border of liver dullness.
 Identify the upper border of liver dullness in the mid-clavicular line by lightly percussing from
lung resonance down toward liver.

An alternate method of estimating liver size is the scratch test.

 Keep the diaphragm of your stethoscope over the liver dullness.

 Start scratching the abdominal wall starting from the right lower quadrant parallel to the liver
edge.
 There will be a sudden transition of increased transmission of sound once the liver edge is
reached.
 Similar maneuvers will determine the upper edge.

Normal:

Liver span in the mid-clavicular line is 6-12 cm.

 Abnormal Finding

 Large Liver: A large list of local and systemic diseases.

 Small Liver: (Hepatic necrosis)

Knowledge Base

Anatomy of liver relationships: (autopsy, drawing)

Physiology of diaphragmatic motion and its effect on liver

Pathology of liver lesions

 Malignancy: Hepatoblastoma (Cut surface)

  Metastatic: Carcinoid (Cut surface)
 Cirrhosis
 Hepatitis
 Sarcoidosis
 Fatty Liver
 Nutmeg Liver

Spleen
To detect enlargement of spleen

Method Of Exam

Author: A. Chandrasekhar Consultant: J. Pickleman

and M. Klamat
 Attempt superficial palpation of abdomen.
 Start in the right lower quadrant and proceed diagonally toward the left upper quadrant.
 Attempt to feel spleen with superficial palpation technique
 With each step, ask the patient to take a deep breath.
 Feel for the tip of the spleen.

Bimanual palpation

Stand on the patient's right side and with your left hand, pull the patient's rib cage anteriorly and palpate for
the tip of the spleen (if enlarged) with your right hand as the patient takes a deep breath.

Alternate method of exam: An alternate method can be utilized if the spleen tip was not palpable by the
other methods. Position the patient in the right lateral decubitus position (legs somewhat flexed at the hips
and knees). In this position gravity may bring the spleen downward.

Normal: In adults a normal spleen is not palpable.

Caution: Repeated rough multiple examinations can cause splenic rupture and hemorrhage.

You should try to palpate spleen by superficial palpation and not deep palpation. Splenic tip is just hugging
anterior abdominal wall. With superficial palpation, let the splenic tip come and touch your fingers with
deep breathing rather than you going after spleen.
 Abnormal Finding

If the Spleen is enlarged describe how many fingers below costal margin, consistency, surface and
tenderness. Spleen can be enlarged due to a variety of diseases. Following are few of the common
diseases.

 Splenomegaly: (Cirrhosis, Hemoglobinopathy, Myelofibrosis, SBE, Typhoid, Lupus, Sarcoidosis,

Lymphoma )
 Tenderness: (Infarct, Hemorrhage, Infection, SBE, Typhoid)
 Consistency: Soft (Typhoid), Firm (cirrhosis, hemoglobinopathy

Knowledge Base

Anatomy of spleen
Charecteristics of normal Spleen

Physiology of diaphragmatic motion and its effect on spleen

Effect of gravity on splenic location

Pathology of splenic lesions

 Acute Lymphatic Leukemia

 Extramedullary hematopoesis/Myelofibrosis
 CLL
 Portal Hypertension
 Typhoid