The inspection continues even though the patient remains fully clothed and the 'formal' physical examination has not yet begun. Dress, too, may give a clue to occupation or hobby, grooming may be related to the conscientiousness with which the patient may follow a health care plan, and a bulging shirt pocket may be stuffed with an open package of cigarettes, an important clue to the possibility of a chest problem. Two examples are respiratory acidosis and cerebral metastases from primary carcinoma of the lung. Not only may a voluntary smile be helpful in assessing neurologic function, but also inspection of the teeth at that time (even though you are just starting to take the history) may reveal extensive pyorrhea that serves to alert the clinician to a dental problem that has a potential as a bacterial source for necrotizing pneumonia.Īs the interview continues, assessment of the level of consciousness and the appropriateness of behavior may lead one to suspect a primary pulmonary process that secondarily produces alterations of central nervous system function. Similarly, active observation skills are used to search for the use of pursed lips during expiration, the activity and development of the sternocleidomastoid muscles, the use of other accessory muscles of ventilation, the presence of shoulder girdle fixation in relationship to the use of these accessory muscles, the flaring of the nasal alae, the presence of jugular venous distention, the degree of comfort, and, as discussed in previous chapters, the presence of cyanosis and clubbing. Specifically, one must note the dynamics of the patient's facial expression in relationship to physiologic activities (inspiration and expiration) and to the questions asked by the examiner. Even as the first serious question of the fully dressed patient is asked, the inspection begins through active observation. It begins with the initial greeting and continues uninterruptedly during the entire data collection process. It is done with the eyes and the intellect. Inspection ( Table 46.1) is an active process. Auscultation, a more sensitive process, confirms earlier findings and may help to identify specific pathologic processes not previously recognized. Palpation, confirmed by percussion, assesses for tenderness and degree of chest expansion. The inspection process initiates and continues throughout the patient encounter. The pulmonary examination consists of inspection, palpation, percussion, and auscultation. By the time the physical examination is complete, even before laboratory evaluations are initiated, the diagnosis should be reasonably certain.

When using this process, it is unusual for two consecutive chest examinations to be identical.

Experienced clinicians exploit the history to help them 'look' for specific physical findings to answer questions posed by the totality of data collected previously. The history determines the examination format.

The examiner extends a hand in greeting, asks about the symptoms that initiated the visit, and begins physical inspection, noting body position, assessing degree of comfort, inspecting and palpating the hands, and noting grip strength. The physical examination begins with the commencement of history taking. The setting for the chest examination must be environmentally comfortable for both clinician and patient.

Hyperresonant lung sounds