clerkship handbook - University of Hawaii – Department of Medicine

6. THORAX:
POSTERIOR THORAX: Inspect thorax and palpate entire spine. Percuss at costovertebral angles -w ith
fore-w arning Percuss for diaphragmatic excursion, from mid-thorax dow n to dullness before and after
deep inspiration on each side. Percuss bilateral chest w all at equivalent areas looking for
hyperresonance or dullness. Auscultate posterior and lateral lung fields -w ith diaphragm of
stethoscope, w hile patient is deep-breathing w ith mouth open. Compare side to side in equivalent
areas.
Patient sitting: physician facing patient.
ANTERIOR THORAX: Inspect. Auscultate anterior lung fields beginning w ith supraclavicular areas
bilaterally w ith deep breathing.
Patient supine: physician at right.
AXILLAE: Palpate w ith passive abduction-adduction (R hand for L axilla and
vice versa).
BREASTS: Inspect and palpate in all quadrants and nipples bilaterally.
7. CARDIOVASCULAR:
NECK: Inspect veins. Palpate carotid pulses on each side one at a time.
Auscultate carotids bilaterally.
HEART: Inspect precordium. Palpate apical impulse (PMI) and entire precordium w ith R hand.
Auscultate w ith diaphragm of stethoscope all cardiac areas (aortic, pulmonic, LSB and apex) w ith
concurrent left finger palpation of right carotid pulse for time of the heart sounds. Auscultate at
pulmonic area for split S2 during inspiration. Auscultate at apex w ith bell of stethoscope (supine,
and in left lateral decubitus position, for presence of S3, S4 and murmur).
8. ABDOMEN:
ABDOMEN: Begin by inquiring about pain. Alert patient. Ask patient to flex hips
and knees to relax abdominal wall muscles.
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