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Physical Diagnosis II


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a and v wave examination

lie on back, without pillow, head of bed 15-30 degrees above horizontal.

 head turned slightly down and right to relax sternocleidomastoid muscle

shadows of light seen on sheet behind patient

time with cardiac or carotid pulse&nb

a wave
increase in right atrial pressure due to right atrial contraction
closing of aortic valve
Similarities/Differences Questions
Increased activity that is apparently purposeless
No movement
amplitude of pulse
normal, diminished, increased, double-peaked
Aortic Auscultation
2nd intercostal spac, right sternal border (2ICS-RSB)
Temporary cessation (i.e. cardiac arrest)
Approach to treat patient with acute respiratory infection
  • upper vs. lower respiratory tract
  • causative agents
  • virulence vs. host response
  • preventive interventions
Arterial Pulse

Produced by ejection of blood into the aorta during systole

Smooth and rapid upstroke following S1, followed by anacrotic notch

Peak is smooth and dome shaped, followed by a less steep descent to dicrotic notch 

Barrel Chest

AP diameter equals lateral diameter

i.e. advanced COPD 

2nd Intercostal Space to right and left of atrium
Best location to hear S2
Best Location to hear splitting of S1
Tricuspid area
Best location to listen to S1
Cardiac Apex
irregular with long periods of apnea; i.e. increased intracranial pressure, drug-induced, brain damage
Boundaries of lungs

Pyramidal Shape

3-4 cm above medial end of clavicle

Inferiorly to rib 6 at midclavicular line, rib 8 at midaxillary line, posteriorly to level of T9 and T12 

Slow movement
abnormal slowing
Breathing muscles
  • Sternocleidomastoid (SCM)
  • Intercostal
  • Diaphragm
  • Abdominal

loud, high pitched like air rushing through a tube over manubrium

expiratory is longer and louder

pause btwn components 


Increased transmission of spoken word

"ninety-nine" is louder if consolidation 


heard in carina and mainstem bronchi

Inspiratory = expiratory 

c wave
increase in right atrial pressure due to tricuspid valve closure secondary to right ventricular contraction
Cardiac Rhythm
  • regular
  • regularly irregular
  • irregularly irregular
Characterization of Murmurs
  • location
  • radiation
  • duration
  • intensity (I-VI)
  • pitch
  • quality
  • relationship to ventilation or body position
Chemoprevention of CHD
  • anti-hypertensives
  • low dose aspirin
  • dietary supplement
  • estrogen replacement
Chest Wall Expansion

normal expansion shows symmetry

localized pulmonary disease may result in lack of symmetry 

irregular with periods of increased and decreased rate and depth and apnea (i.e. drug-induced, brain damage, congestive heart failure (CHF))
Brief, rapi, sudden, arrythmic, involuntary; dance over body

cramps in calf brought about by exercise and relieved by rest, due to insufficient blood flow to the extremity

Dorsalis pedis (pedal) and posterior tibialis pulses impt. 


Ability of the patient to think and reason. Most cognitive eval. is completed via the Mini Mental State Exam.

Also includes: level of conscious awareness, genearl intellectual function, and abstraction.

Components of the Mental Status Exam
  • Appearance and Behavior
  • Motor Activity
  • Mood and Affect
  • Speech and Language
  • Thought Content
  • Perception
  • Insight
  • Judgement Cognition
Affect and mood in agreement (versus incongruent)
Contour of Pulse
shape of the wave, speed of the upslope, downslope, duration of wave

Chronic Obstructive Pulmonary Disease

  1. emphysema
  2. chronic bronchitis 

short, discontinuous, nonmusical sounds heard on inspiration

caused by opening of collapsed distal airways or alveoli 

rales, crepitation

pulmonary edema, CHF, pulmonary fibrosis, bronchitis, resp. infection, atelectasis 


Mental disturbance of short duration, usually reflecting a toxic state, marked by illusions, hallucinations,, delusions, excitement, restlessness, and incoherence. 

May be superimposed on demnentia. 


Organic mental syndrome characterized by a general loss of intellectual abilities, involving impairment in judgement and sbstract thinking as well as changes in personality, but not including that due to clouding of consciousness, depression, or other

Diastolic AV murmur
begins after a finite time after S2 with opening of AV valve (mitral or tricuspid stenosis)
Diastolic opening snaps
high-pitched sharp sound due to opening of defective AV valve
diastolic pressure
pressure at which sounds vanish
Diastolic Semilunar Murmur
begins immediately after S2 (aortic or pulmonic regurgitation)
Dicrotic Notch
closure of the aortic valve

low amplitude, short duration

solid organ (liver) 

Unhappy-appearing (affect) or unpleasant (mood)
Sustained abnormal posture of muscle spasm

spoken word heard through lungs is increased in intensity and takes on a nasal quality

"eee" heard as "aaa" in area of consolidation (fluid-filled) 

Ejection Click
Early in systole, due to defective opening of semilunar valve
Ejection murmur
turbulent flow across a semilunar valve in systole (aortic or pulmonic stenosis)
Elements of Medical History
  1. Chief Complaint (CC)
  2. History of Present Illness (HPI) including Coarse
  3. Past Medical History/Meds/Allergies
  4. Family History
  5. Social History
  6. Review of Systems
Emerging CHD Risk factors
  • thrombogenic factors
  • homocysteine
  • c-reactive protein
  • psychologic stress
  • infection
Erb's Point Auscultation

3rd Intercostal spac, left sternal  border (3ICS-LSB)

 Area where aortic and pulmonic sounds radiate

Elated, "high"
Normal mood
Examination of Chest

Both posterior and anterior:

  1.  Inspection
  2. Palpation
  3. Percussion
  4. Auscultation
Femoral pulse

2-3 cm inferior from inguinal ligament

Diminished pulse suggests arterial insufficiency 

Flail Chest

one chest wall moves paradoxically inward during inspiration

i.e. multiple rib fractures 


high pitched

large muscle mass (thigh) 

Folstein Mini Mental State exam

Abbreviate, standardized mental status exam with 30 point max score.


  • Orientation
  • Registration
  • Attention and Calculation
  • Recall
  • Language 
General Intellectual Function
Determined by asking the patient about current events
Heart Exam
  1. Inspection
  2. Blood Pressure
  3. Arterial Pulse
  4. Jugular Venous Pressure
  5. Percussion
  6. Palpation
  7. Auscultation
  8. Exam for Dependent Edema (graded 1+ to 4+)
Heart Murmurs

noise events that last longer than a second heart sound, generated by turbulent blookd flow


  • valvular opening decreases, increases in size, becomes irregular in shape
  •  ejection velocity increases
horizontal fissure

only in right lung

separates upper and middle lobes

runs from sternal border at rib 4 to midaxillary line at rib 5 


a.k.a. Kussmaul's

increased depth, usually associated with metabolic acidosis 


low pitched, hollow

(emphysemic lung) 

Inferior wing of scapula
Rib 7
Inflation pressure

inflate cuff until radial pulse disappears, add 30 mm Hg and this is inflation pressure to use

Deflate cuff and wait 15-30 sec 


Observe what patient says about their illness. If understanding is less than complete, need more direct questions.

Impt. component of competency evaluation. 


How they are handling decisions about their own day-to-day affairs.


Impt. component of competency evaluations 

Jugular venous pulse

considerably increased in certain heart conditions (mitral valve disease)

Kortokoff sounds
low-pitched sounds heard during deflation of BP cuff when determining BP
abnormal AP diameter and lateral curvature of the spine
Highly variable and quickly changeable
Left atrium
Most posterior portion, moves posteriorly and to the right when enlarged
left lung
2 lobes: upper, lower
Left Ventricle
Left and behind right ventricle
Left Ventricular Apex
5th intercostal space at midclavicular line (5ICS-MCL)
Length best heard

anteriorly - 1st and 2nd intercostal spaces

posteriorly - scapulae 

Level of Conscious Awareness
Posited on a continuum from normal alertness to coma
location of diapraghm

at end of expiration, passive process producing elastic recoil of the muscle

Anteriorly - rib 5

Posteriorly - T9 

right hemidiaphragm is slightly higher than left because of liver on  right side

Major Diseases of the Heart
  • Coronary Artery Disease
  • Hypertension
  • Rheumatic Heart Disease
  • Bacterial Endocarditis
  • Congenital Heart Disease
An unusual way of performing a functional motor act (i.e. waving goodbye with both hands)
Metabolic Syndrome
  • insulin resistence
  • hypertension
  • dyslipidemia
  • Obesity
Midsystolic click
middle of systole, single or multiple, may change position. May be due to prolapse of mitral or tricuspid valve.
Mitral Auscultation
Cardiac apex(5CIS-MCL)
Mitral opening snap
mitral stenosis, occurs after A2
Modifiable Risk Factors for CHD
  • high sat. fat diet
  • smoking
  • alcohol
  • physical inactivity
  • High BP
  • High LDL
  • Low HDL
  • High Triglycerides
  • Glucose Intolerance
  • Obesity
normal BP

up to 120/80

5-10 mm Hg difference btwn arms is normal 

Normal Chest
wider later diameter than AP diameter
Normal Jugular Venous Pressures
  • 0 - sternal angle
  • 30 - 6 cm above sternal angle
  • 45 - 4-5 cm above sternal angle
Normal Respiration Rate
10-14 breaths per minute
oblique fissure

separates lower lobe from rest of lung in both lungs

rib 6 at midclavicular line to rib 5 at midaxillary line then posteriorly to T3 

Observation of jugular vein

may be a sign of:

  • heart failure
  • obstruction of SVC
  • enlarged supraclavicular nodes
  • increased intrathoracic pressure 
closing of pulmonic valve
Palpation of Chest

Evauate position of trachea

deviation may be due to a mass or something that would shift the mediastinum 

Palpation of Heart
  • apical impulse
  • right ventricle
  • pulmonary artery
  • left ventricular motions
  • PMI
  • PMI after running for 1 min
  • second interspace
  • aortic area
  • pulmonic area
  • generalized motion
Palpation of the arterial pulse

Yields information about:

  • rate and rhythm of heart
  • contour of pulse
  • amplitude of pulse 
Parameters of affect
  • Range
  • Intensity
  • Stability
  • Appropriateness
  • Relatedness
Parameters of Language
  • Complexity
  • Comprehension
  • Coherence
Parameters of Motor Activity
  • amount
  • speed
  • posture
  • gait
Parameters of Speech
  • amount
  • speed
  • volume
  • clarity
  • fluency
Pectus Carinatum

Anterior protrusion of sternum; usually does not compromise ventilation  (a.k.a. pigeon chest)

Pectus Excavatum
depression of sternum; usually accompanied by mitral valve prolapse

Patient usually needs to be asked to elicit information

Occurs in different modalities (auditory, olfactory, visual, gustatory, and tactile)

Can be positive, negative, and distorted 

Percussion of chest
used to detect density of underlying structures - depends on air-to-tissue ratio
Period between S1 and S2
Period between S2 and S1
Physiologic Splitting of S2
A2 normally precedes P2, gap widens due to inspiration
pleural rubs

grating sound made by pleura that is roughened or thickened by inflammation, neoplasm, or fibrin deposits

best heard on inspiration and beg. of expiration

creaking leather

associated with pneumonia and pulmonary infarction 


point of maximal impulse

left ventricular apex 

Prevention of TB


  • Prevention of disease after Infection
  • Prevention of Transmission


  •  screening for latent infection
Problem List/Clinical Impression
  • Diagnosis - high resolution
  • Collection of symptoms
  • Pathophysiologic state
  • A physical finding(s)
  • A lab abnormality(ies)
  • A psycho-socio-economic issue
Proper BP cuff size
20% wider than the diameter of the extremity
Proper level of BP cuff
heart level for accurate measurement and patient's arm should be supported at level of patient's heart
Psychomotor retardation
Visible generalized slowing of movements and speech
Pulmonic Auscultation
2nd Intercostal Space (2ICS-LSB)
Pulse deficit

may occur in irregular heart rhythm

Difference between apical (taken at apex of heart) and radial pulse  

If exists, then true heart rate can only be obtained by auscultation at apex of heart 

Pulse sites
  1. Radial (brachial in neonates and infants)
  2. Carotid
  3. Femoral
  4. Dorsalis pedis
  5. Porterior tibialis
Regurgitant systolic murmur
retrograde flow from from higher pressure area to lower pressure area during systole (mitral or tricuspid regurgitation)

higher amplitude, low pitched

air filled tissue (lung) 



associated with mucous plgging and poor movement of secretions

associated with bronchitis 

Right Atrium

3rd-5th ribs on right of sternum 

Right lung
3 lobes: upper, middle, lower
Right Ventricle

Most of anterior surface of heart 

Risk Factors for depression
  • S - sleep disturbances; is sleep increased or decreased?
  • I - Interest; what gives the patient pleasure;does he have the same pleasures?
  • G - Guilt
  • E - Energy Level
  • C - Concentration
  • A - Appetite
  • P - P
Closing of the AV valves (tricuspid and mitral)
Closing of the semilunar valves (Aortic and Pulmonic)

heard immediately after S2.

Normal in children and young adults

when heard in >30 y.o. may signify volume overload to the ventricle. May be due to regurgitant lesion in valves and congestive heart failure. Produces a gallop sound or rhy


When produced is heard after diastole when atrial contraction occurs.

Normal in young adults and children

when heard in >30 y.o. may indicate noncompliant or stiff ventricle. 

Social History
  • Birthplace
  • Marital
  • Children
  • Vocation
  • Avocations (Hobbies)
  • Habits
Sounds best heard with bell

low-pitched sounds such as gallop rhythms, AV stenosis murmurs

 Press lightly against skin

Sounds best heard with diaphragm

high-pitched sounds such as valve closure, systolic events, regurgitant murmurs

 Press tightly to skin

Sternal Angle (of Louis)

Important landmark for: 

  • Rib 2
  • Bifurcation of trachea to bronchi
  • Carina
  • T4 
Symptoms of Cardic Disease
  • Chest pain
  • Palpitations
  • Dyspnea
  • Syncope
  • Fatigue
  • Dependent edema
  • Hemoptysis
  • Cyanosis
Symptoms of Pulmonary Disease
  • Cough
  • Sputum production
  • Hemoptysis - coughing up blood
  • Dyspnea - shortness of breath
  • Wheezing
  • Cyanosis - bluish discoloration of skin
  • Chest pain
Systolic Clicks
high-pitched, short, "click" sounds that are produced by the opening of a pathologically deformed valve.
systolic pressure
pressure level at which you hear 2 consecutive beats
Abnormal increase
Tactile Fremitus

vibration felt on the chest wall when the patient is speaking

Provides info on the density of the underlying tissue

Increased density -> increased vibration -> increased tactile fremitus

fat, air, or fluid will decrease density<

The sound heard with the carotid pulse
Things to Note for Appearance and Behavior
  • body type
  • physical stigmata
  • posture
  • bearing
  • clothes
  • grooming
  • alertness
  • level of comfort
  • ambulation status
  • unusual or repetitive behaviors
Thought Content
  1. Preoccupations
  2. Disturbances (such as delusions)

Can be transient or fixed. Can make some observations but in general, the patient must be asked about this part of the MSE.

  • Suicidal Thoughts or plans
  • Hom
An involuntar, sudden, rapid, recurrent, non-rhythmic, stereotyped movement or vocalization

harsh, loud, high pitched

heard over trachea

inspiratory and expiratory are equal in length 

Rhythmic oscillation of a body part
Tricuspid Auscultation
Left lower sternal border (LLSB)
tricuspid opening snap
tricuspid stenosis, occurs after P2

high pitched, hollow

hollow, air filled organ (stomach) 

Types of normal breathing
  1. Tracheal
  2. Bronchial
  3. Vesicular
  4. Bronchovesicular
Unmodifiable Risk factors for CHD
  • Age
  • Sex
  • family history
  • personal history
v wave
increase in right atrial pressure due to its filling during ventricular systole

soft, low pitched heard over most of lung fields

inspiratory is louder and longer 


continuous, musical, high-pitched - heard during expiration

caused by narrowing of bronchi due to swelling, secretion, foreign body, tumor

associated with asthma, pumonary edema, bronchitis, CHF 

whispered pectriloquy

intensification of whispered word heard in consolidation of lung

"one-two-three" clearly heard when whispered in consolidation of lung 

x descent
decrease in right atrial pressure due to atrial relaxation
x' descent
decrease in right atrial pressure due to increasing size of atrium secondary to right ventricular contraction
y descent
decrease in right atrial pressure due to tricuspid valve opening at end of ventricular systole

Deck Info