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Clinical examination of the

thorax, abdomen and pelvis

Justin Wu

Department of Medicine & Therapeutics

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Approach to clinical problem

History taking

Ask questions about the current symptom and

background of the patient Physical examination

Look for abnormal signs as guided by history

taking

Investigation

Laboratory or imaging tests based on history

and physical examination

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Rule of thumb

Most organs have their constant surface

landmarks, boundaries and physical

properties

The size, position and physical properties are

altered in many diseases

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Hypogastrium

Left lumbar

Left

hypochrondium

Right

hypochrondium

Right lumbar

Left iliacRight iliac

Umbilical

Epigastrium

Abdomen

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Left upperquadrant

Left lower

quadrant

Right upperquadrant

Right lower

quadrant

Abdomen

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Palpation of Abdomen

CecumAppendix

Uterus

Urinary

bladder

Sigmoid

L. Kidney

Des. colon

Spleen

Stomach

Trans. colon

Liver

Gallbladder

R. Kidney

Asc. colon

Aorta

Pancreas

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Palpation of Abdomen

CecumAppendix

Uterus

Urinary

bladder

Sigmoid

L. Kidney

Des. colon

Spleen

Stomach

Trans. colon

Liver

Gallbladder

R. Kidney

Asc. colon

Aorta

Pancreas

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4 steps of clinical examination

Inspection (Look)

Palpation (Feel)

Percussion (Tap)

Auscultation (Listen)

Detect abnormal anatomy

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Palpation of liver

Costal margin

5thintercostal space

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Palpation of liver enlargement

(Hepatomegaly)

Descend with respiration

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Costal margin

Palpation of spleen

9-11thribs

Midaxillary line

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Palpation of spleen

Push forward

Feel

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Palpation of spleen enlargement

(Splenomegaly)

Push forward

FeelDescend with respiration along the diagonal

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Feel

Bimanual palpation of kidney

Push upward

Descend vertically

with respiration

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Bimanual palpation of kidney

Feel

Push upward

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Percussion

Solid / Fluid : DullAir : Resonant

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Liver Spleen

KidneyKidney

DullDull

ResonantResonant

Bowel gas

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Resonanton percussion

Percussion of liver

Percuss the upper border

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Dullon percussion

Percussion of hepatomegaly

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Percussion of spleen

Resonanton percussion

Midaxillary line

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Percussion of splenomegaly

Dullon percussion

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Percussion of bladder

Dull on percussion

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Percussion for fluid in peritoneum

Resonanton percussion

Shifting Dullon

percussion

Fluid

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Auscultation

Bowel sound

Bruit (turbulence caused

by abnormal artery)

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Digital examination of rectum

Prostate

Seminal

vesicle

Cervix

Vagina

Pouch of

Douglas

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Thorax

Precordium: Heart

Chest: Lungs, trachea

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Precordium

Apex beat Contraction of left ventricle

Change in position indicates enlargement or

thickening of L. ventricle Heart sounds

Closure of heart valves

Murmur Turbulence generated in valve abnormalities

Heart sounds and murmur often radiated to sitesaway from the original position of valve

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Apex beat always at 5th

intercostal space on mid-clavicular line

Palpation of apex beat

Apex beat = Most

inferior and lateral area

of palpable pulsation

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Apex beat is displaced incardiomegaly

Palpation of apex beat

Aortic valve at 2nd ICS on the right

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Auscultation of heart sounds

Sternal angle

A

P

MT

Aortic valve at 2ndICS on the right

side of sternum

Pulmonary valve at 2ndICS on theleft side of sternum

1stheart sound at LLSB

Closure of tricuspid valve

1st

heart sound at apexClosure of mitral valve

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Auscultation of heart sounds

Mitral valve

Tricuspid valve

Pulmonary valve

Aortic valve

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Chest

Both lungs always expand symmetrically

Abnormal lung expands less

Normal lung is filled with air

Abnormal lung may contain fluid or solid

Abnormal breathing sound can be caused by

abnormal anatomy of airway or altered

physical properties of lung

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6th

rib

Surface anatomy of lungs10thrib

T3 vertebra (Root of

spine of scapula)

Scapula

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Percussion of upper lobe

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Percussion of upper lobe

4thICS

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Percussion of middle lobe

Lingula6thrib

4thICS

AirResonant

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Percussion of middle lobe in pneumonia

Lingula6thrib

4thICS

Consolidation

(Hardening)Dull

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Percussion of middle lobe in pleural effusion

Lingula6thrib

4thICS

EffusionStony Dull

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Avoid the cardiac dullness

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Auscultation of breath sound

X

X

X

X

X

X

X

X

X

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Auscultation of breath sound

Effusion, collapse, pneumothorax:

Air entry

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Remember the surface anatomy!