Assessment and Diagnosis · 4 min read
Physical Assessment
Physical assessment uses four techniques in a set order for most body systems: inspection, palpation, percussion, and auscultation. The abdomen is the exception: inspect, auscultate, then percuss and palpate, because palpation can alter bowel sounds.
Percussion: Technique and Sounds
Percussion sets underlying tissue in vibration to judge density, organ size, and the presence of air, fluid, or solid tissue. In indirect (mediate) percussion, the distal phalanx of the middle finger of the nondominant hand (pleximeter) is pressed firmly on the skin and struck with the tip of the middle finger of the dominant hand (plexor) using a quick, relaxed wrist motion. Direct percussion taps the surface itself, as over the sinuses. Fist percussion over the costovertebral angle elicits tenderness in pyelonephritis.
| Sound | Quality | Normal location | Abnormal meaning |
|---|---|---|---|
| Tympany | Loud, high-pitched, drum-like | Gastric bubble, gas-filled bowel | Over the liver: free air (pneumoperitoneum) |
| Resonance | Hollow, moderate pitch | Healthy lung | Expected finding over lung fields |
| Hyperresonance | Louder, lower-pitched, booming | Not normal in adults | Air trapping: emphysema, pneumothorax |
| Dullness | Soft, high-pitched thud | Liver, spleen, full bladder | Over lung: consolidation, pleural effusion, atelectasis, mass |
| Flatness | Very soft, short | Thigh muscle, bone | Over lung: massive effusion |
Thoracic Assessment
Percuss the posterior chest with the patient sitting, arms crossed to move the scapulae laterally, comparing side to side from apex to base. Unilateral reduction in diaphragmatic excursion suggests pleural disease or diaphragmatic paralysis.
| Condition | Percussion | Tactile fremitus | Breath sounds | Trachea |
|---|---|---|---|---|
| Normal lung | Resonant | Normal | Vesicular | Midline |
| Lobar consolidation (pneumonia) | Dull | Increased | Bronchial; crackles; egophony | Midline |
| Pleural effusion | Dull, may shift with position | Decreased | Decreased or absent | Midline or away (large effusion) |
| Pneumothorax | Hyperresonant | Decreased | Decreased or absent | Away from affected side in tension |
| Emphysema | Hyperresonant | Decreased | Decreased; prolonged expiration | Midline |
| Atelectasis (large) | Dull | Decreased | Decreased | Toward affected side |
Adventitious Breath Sounds
| Sound | Description | Common causes |
|---|---|---|
| Fine crackles | Brief, high-pitched popping at end of inspiration | Heart failure, pneumonia, pulmonary fibrosis, atelectasis |
| Coarse crackles | Low-pitched bubbling | Secretions in larger airways, pulmonary edema |
| Wheezes | Continuous musical sound, often expiratory | Asthma, COPD, bronchospasm |
| Rhonchi | Low-pitched snoring; may clear with coughing | Secretions in large airways |
| Stridor | High-pitched inspiratory sound over the upper airway | Upper airway obstruction: emergency |
| Pleural friction rub | Grating sound in both phases; does not clear with coughing | Pleuritis, pulmonary embolism |
Abdominal Assessment
- Liver span: 6–12 cm in the right midclavicular line. Increased span suggests hepatomegaly; loss of liver dullness can indicate free air.
- Spleen: dullness should not extend anterior to the midaxillary line; a change from tympany to dullness on inspiration (Castell sign) suggests splenomegaly.
- Ascites: bulging flanks, flank dullness with central tympany, shifting dullness when the patient turns, and a fluid wave.
- Bladder: suprapubic dullness indicates distension; confirm retention with a bladder scanner.
Cardiovascular and Neurovascular Checks
| Finding | Interpretation |
|---|---|
| Pitting edema 1+ to 4+ | 1+ = 2 mm, rebounds quickly; 4+ = 8 mm or deeper, lasting more than 2 minutes |
| Jugular venous distension at 45 degrees | Elevated right-sided pressure: heart failure, fluid overload, tamponade |
| S3 gallop | Ventricular volume overload; heart failure in adults |
| Capillary refill > 3 seconds | Reduced peripheral perfusion |
| Six Ps of neurovascular compromise | Pain (out of proportion, with passive stretch), pallor, pulselessness, paresthesia, paralysis, poikilothermia; pain and paresthesia occur early in compartment syndrome |
Level of Consciousness: Glasgow Coma Scale
| Component | Best response scored |
|---|---|
| Eye opening (1–4) | 4 spontaneous · 3 to voice · 2 to pressure or pain · 1 none |
| Verbal (1–5) | 5 oriented · 4 confused · 3 inappropriate words · 2 incomprehensible sounds · 1 none |
| Motor (1–6) | 6 obeys commands · 5 localizes · 4 withdraws (normal flexion) · 3 abnormal flexion (decorticate) · 2 extension (decerebrate) · 1 none |
- Abdomen: inspect, auscultate, percuss, palpate.
- Dull lung + increased fremitus = consolidation; dull + decreased fremitus = effusion; hyperresonance = air.
- Stridor is an airway emergency.
- Pain on passive stretch is an early sign of compartment syndrome; pulselessness is late.
- GCS of 8 or less: protect the airway.
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