Examination of the Thorax, Lung, Abdomen,

and Extremities
Examination of the Thorax and Lungs
Lung Anatomy
Understanding the pulmonary exam is greatly enhanced by recognizing the
relationships between surface structures, the skeleton, and the main lobes of the
lung.
Lung Topography
 To perform an accurate physical assessment of the thorax and lungs, the RCP must
first identify key landmarks.
 Topographic or surface landmarks on the chest help one identify the location of
underlying structures or abnormalities.
 In addition, Imaginary lines are used to describe the location of anatomic
structures within the chest and abnormal physical examination findings.
Imaginary Lines:
 Midsternal line
- divides the chest into equal halves (right and left midclavicular lines parallel the
midsternal line)
 Midaxillary line
- Divides the lateral chest into equal halves (anterior axillary line and posterior
axillary line
 Midspinal line

- Divides the posterior chest into two equal halves ( left and right midscapular lines)
Thoracic cage
landmark
Thorax and Lung
Thoracic cage is a bony structure defined by the sternum: 12 pairs of ribs, 12
thoracic vertebrae.
 Floor is the diaphragm (musculotendinous septum separates the thoracic
cavity from abdomen).
 First seven ribs attach directly to the sternum via costal cartilages. Ribs 8, 9,
10 attach to costal cartilage above. Ribs 11 & 12 “floating” with free
palpable tips costochondral junctions are points where ribs join their
cartilages (not palpable).
Anterior Landmarks
 Suprasternal Notch: “U” shaped depression above sternum-between
clavicles.
 Sternum: “Breastbone” 3 parts:
Manubrium, Body, Xiphoid Process
 “Angle of Louis” Marks site of tracheal bifurcation into Right and Left main
bronchi. Approximately 2.5 cm below sternal notch.
 Costal Angle: Right and Left costal margins form an angle where they meet
at the Xiphoid Process.
Posterior Landmarks
 Vertebra Prominens: Most bony spur protruding at the base of the neck.
This is the spinous process of C7.
Thoracic Cavity
 Mediastinum: Middle section of the thoracic cavity-contains esophagus,
trachea, heart, great vessels
 Pleural cavities: R & L lung
 Lung Borders:
- Anterior chest: Apex-highest point lung tissue. 2-4 cm above inner third
clavicles. Base lower border, rests on diaphragm 6th rib midclavicular.
- Laterally lung tissue goes from the apex of the axilla down to the 7 th or 8th
rib.
Lobes of the Lungs
 Right lung shorter than left because of the liver.
 Right lung has 3 lobes.
 Left lung has 2 lobes.
 Lobes are stacked in diagonal sloping segments separated by fissures
that run obliquely throughout the chest.
 Anterior chest almost all upper and middle lobe with very little lower
lobe.
 Posterior chest contains almost all lower lobe.
Pleura of The Lungs
 Parietal Pleura: The outer lining of each lung. It is attached to the
chest wall.
 Visceral Pleura: The inner lining of each lung. It is attached to the
lung itself.
 Pleural Space: Is the space created between these two linings and it
is filled with a small amount of lubricating fluid called Pleural Fluid.
 Negative Pressure holds lungs tightly against chest wall and
maintains inflation.
Trachea & Bronchial Tree
 Trachea is anterior to the esophagus & transports air to the bronchi.
 Bronchi are large “air tubes” leading from the trachea that conducts
air into lungs.
 Trachea & bronchi transport gases between environment and lung
parenchyma.
 Alveoli are the primary site of gas exchange.
Mechanics of Respiration
 The Mechanism of Breathing maintains PH of the blood by supplying
oxygen & eliminating excess carbon dioxide.
 With Inspiration the size of the thoracic container increases creating a
slightly negative pressure in relation to the atmosphere, air rushes in.
 Major muscle responsible for this increase is the diaphragm.
 Inspiration – contraction of the diaphragm causes it to descend and
flatten.
 Expiration – passive, relaxation of the diaphragm
Inspiration & Expiration
 Inspiration: Intercostal muscles lift the sternum and elevate the ribs,
diaphragm descends.
 Expiration is primarily passive. As diaphragm relaxes - it is forced to
dome up.
 This results in air flowing out due to positive pressure within the alveoli.
 Respiratory center in the brain stem (Pons & medulla).
Assessment:

Inspection:General Appearance
 Restless or agitated
 Flaring nostrils
 Supraclavicular retractions
 Intercostal retractions
 Use of accessory muscles

Cyanosis:
 Central Cyanosis: Circumoral (around mouth), check lips, tongue,
buccal mucosa.
 Peripheral Cyanosis: check nail beds and extremities.
 Check nails for clubbing.

Cough: productive or non-productive

 Inspect appearance of sputum: Mucoid vs Purulent
 Musculature: Check accessory muscles: Sternomastoid, Intercostals,
Scalene, Ala Nasi
 Symmetry: Check symmetrical expansion of chest wall.
• Bilateral diminished expansion may be due to acute pleurisy, pleural
fibrosis, atelectasis, chest pain (fx. ribs), Costochondritis.
• Unilateral diminished expansion may be due to pneumothorax.
• Check for asymmmetry of spine:Kyphosis, Lordosis, Scoliosis.
 Configuration & Contour: Check AP diameter (AP to transverse diameter).
• Abnormal:
- Barrel chest
- Pectus Carinatum
- Pectus Excavatum
 Movement: Breathing patterns, smooth & even breathing.
- Passive breathing: normal rate12-20
- Check Character of Breathing: type, rate, rhythm
• Apnea
• Hyperventilation/Tachypnea
• Kussmaul
• Hypoventilation/respiratory depression
• Cheyne Stoking/Dying Sighs
Palpation
 Trachea: Check for deviation
 Thorax: Check for crepitus, tenderness.
 Check for chest wall excursion
 Check for tactile or vocal fremitus: Vibrations produced in the larynx
that are transmitted to the chest wall.
Tactile fremitus
 Increased tactile fremitius occurs in conditions where solid
conducts vibrations better than air. Ex. Pneumonia, tumor,
pulmonary fibrosis
 Decreased tactile fremitus occurs when there is increased distance
that sound has to travel before it reaches chest wall. Ex. Pleural
Effusion, pneumothorax, COPD.
 Palpation of Tactile Fremitus

Chest Wall Excursion

Percussion
 Percuss: Anterior chest, lateral chest, posterior chest
 Normal: Resonance
 Abnormal:Dullness - consolidation, atelectasis, pleural effusion.

Hyperresonance -pneumothorax,emphysema, asthma.

 Diaphragmatic Excursion: Checks ROM of the diaphragm.

Auscultation
 Pt. sit upright, breathe slowly through mouth.
 Use diaphragm.
 Auscultate anterior, lateral and posterior chest.
Types of Breath Sounds
Vesicular Breath Sounds Bronchial (Tracheal)
•Soft and low pitched •Loud and high pitched
•Fine rustling/swishing •Tubular quality
sound.
•Heard on inspiration •Expiration>Inspiration
continuously without pause •Heard only interiorly over
until expiration. trachea & larynx
•Heard over all post. Lung •Expiration loud
fields and anterior peripheral
fields.
•Inspiration> Expiration
Bronchovesicular Breath Sounds
•Combination of vesicular and bronchial sounds
•Represent a mixture of sounds produced by vibrations of bronchial and
alveoli vibrations.
•No pause between inspiration and expiration
•Inspiration = Expiration
•Decreased Breath Sounds: shallow breathing, pleural effusion, COPD,
pneumothorax, asthma, atelectasis.
•Increased Breath Sounds: Consolidation-tumor, pneumonia.
Adventitious Sounds:
Rales (Crackles):
 Discontinuous sounds highpitched.
 Sounds like hair being rubbed together
 Sound produced by air passing through fluid in air spaces (CHF,
pneumonia).
 Usually on inspiration / not expiration
 Cough doesn’t clear

Rhonchi:
 Deeper, rumbling sounds.
 Low pitched, snoring quality
 > pronounced during expiration.
 Etiology: larger airways are obstructed with mucus or tumor in large
airways.
 Clear with coughing.
Wheezing:
 High pitched, musical, whistling sounds
 Produced by narrowed airway
 bronchospasm, asthma, tumor, foreign body
 Can occur during inspiration or expiration.

Stridor:
 increased musical wheeze heard over trachea on inspiration; cause
obstruction
The lung exam

The 4 major components of the lung exam (inspection, palpation,

percussion and auscultation) are also used to examine the heart and
abdomen. Learning the appropriate techniques at this juncture will
therefore enhance your ability to perform these other examinations as
well. Vital signs, an important source of information, are discussed
elsewhere.
Inspection/Observation:
 A great deal of information can be gathered from simply watching a
patient breathe. Pay particular attention to:
1. General comfort and breathing pattern of the patient. Do they appear
distressed, diaphoretic? Are the breaths regular and deep?
2. Use of accessory muscles of breathing (e.g. scalenes,
sternocleidomastoids). Their use signifies some element of respiratory
difficulty.
3. Color of the patient, in particular around the lips and nail beds.
Obviously, blue is bad!
4. The position of the patient.
5. Breathing through pursed lips, often seen in cases of
emphysema.
6. Ability to speak.
7. Any audible noises associated with breathing as
occasionally, wheezing or the gurgling caused by secretions
in large airways are audible to the "naked" ear.
8. The direction of abdominal wall movement during
inspiration.
9. Any obvious chest or spine deformities.

Cyanosis of nail beds

 Pectus excavatum: Congenital posterior displacement of lower aspect
of sternum. This gives the chest a somewhat "hollowed-out"
appearance. The x-ray shows a subtle concave appearance of the lower
sternum.

 Barrel chest: Associated with emphysema and lung hyperinflation.

Accompanying x-ray also demonstrates
increased anterior-posterior diameter as well as diaphragmatic
flattening.
 Spine abnormalities:
 Kyphosis: Causes the patient to be bent forward. Accompanying
X-Ray of same patient clearly demonstrates extreme curvature of
the spine.

 Scoliosis: Condition where the spine is curved to either the left or

right. In the pictures below, scoliosis of the spine causes right
shoulder area to appear somewhat higher than the left. Curvature
is more pronounced on x-ray.
Palpation:
 Palpation plays a relatively minor role in the examination of the normal
chest as the structure of interest (the lung) is covered by the ribs and
therefore not palpable. Specific situations where it may be helpful
include:
1. Accentuating normal chest excursion: Place your hands on the
patient's back with thumbs pointed towards the spine. Remember to
first rub your hands together so that they are not too cold prior to
touching the patient.
Detecting Chest
Excursion
2. Tactile Fremitus: Normal lung transmits a palpable vibratory sensation
to the chest wall. This is referred to as fremitus and can be detected by
placing the ulnar aspects of both hands firmly against either side of the
chest while the patient says the words "Ninety-Nine."

Pathologic conditions will alter fremitus. In particular:

Assessing A. Lung consolidation
Fremitus B. Pleural fluid

3 Investigating painful areas: If the patient complains of pain at a

particular site it is obviously important to carefully palpate around that
area
Percussion:
 This technique makes use of the fact that striking a surface which covers
an air-filled structure (e.g. normal lung) will produce a resonant note while
repeating the same maneuver over a fluid or tissue filled cavity generates
a relatively dull sound.
1. If you're percussing with your right hand, stand a bit to the left side of
the patient's back.
2. Ask the patient to cross their hands in front of their chest, grasping the
opposite shoulder with each hand. This will help to pull the scapulae
laterally, away from the percussion field.
3. Work down the "alley" that exists between the scapula and vertebral
column, which should help you avoid percussing over bone.
4. Try to focus on striking the distal inter-phalangeal joint (i.e. the last joint)
of your left middle finger with the tip of the right middle finger.
5. The last 2 phalanges of your left middle finger should rest firmly on the
patient's back.
6. When percussing any one spot, 2 or 3 sharp taps should suffice, though
feel free to do more if you'd like. Then move your hand down several
inter-spaces and repeat the maneuver.
 Percussion Technique

7. The goal is to recognize that at some point as you move down

towards the base of the lungs, the quality of the sound changes.
8. “Speed percussion" may help to accentuate the difference
between dull and resonant areas.
Auscultation:
 Prior to listening over any one area of the chest, remind yourself which lobe of
the lung is heard best in that region: lower lobes occupy the bottom 3/4 of the
posterior fields; right middle lobe heard in right axilla; lingula in left axilla; upper
lobes in the anterior chest and at the top 1/4 of the posterior fields.
1. Put on your stethoscope so that the ear pieces are directed away from you.
2. The upper aspect of the posterior fields (i.e. towards the top of the patient's
back) are examined first. Listen over one spot and then move the stethoscope
to the same position on the opposite side and repeat.

Lung
Auscultation

3. The lingula and right middle lobes can be examined while you are still standing
behind the patient.
4. Then, move around to the front and listen to the anterior fields in the same
fashion.
Keys to performing a sensitive yet thorough exam:
 Explain what you're doing (" why) before doing it
 Expose the minimum amount of skin necessary - this requires "artful"
use of gown & drapes (males & females)
 Examining heart & lungs of female patients:
• Ask pt to remove bra prior (you can't hear the heart well thru fabric)
• Expose the chest only to the extent needed. For lung exam, you can
listen to the anterior fields by exposing only the top part of the
breasts (see picture below).
• Enlist patient's assistance, asking them to raise their breast to a
position that enhances your ability to listen to the heart
 Don't rush, act in a callous fashion, or cause pain
 PLEASE... don't examine body parts thru gown as:
• It reflects Poor technique
• You'll miss things
Remember - Don't examine thru clothing or "snake" stethoscope
down shirts/gowns
Good exam options
Thoughts On "Gown Management" &
Appropriately/Respectfully Touching Your Patients:
There are several sources of tension relating to the physical exam in
general, which are really brought to the fore during the chest examine.
These include:
 Area to be examined must be reasonably exposed - yet patient kept as
covered as possible
 The need to Palpate sensitive areas in order to perform accurate exam
- requires touching people w/whom you've little acquaintance -
awkward, particularly if opposite gender
 As newcomers to medicine, you're particularly aware that this aspect of
the exam is "unnatural" & hence very sensitive..
Examination of the Abdomen
Examination of the Abdomen
 The major components of the abdominal exam include: observation,
auscultation, percussion, and palpation. While these are the same
elements which make up the pulmonary and cardiac exams, they are
performed here in a slightly different order (i.e. auscultation before
percussion) and carry different degrees of importance. Pelvic, genital,
and rectal exams, all part of the abdominal evaluation, are discussed
elsewhere.
Abdomen
 The abdomen should be inspected and palpate for evidence of
distention and tenderness
 Abdominal distention and pain impaired diaphragm movement and
contribute to respiratory insufficiency or failure
 Also, it may inhibit the patient from coughing and deep breathing

Anatomically
 The abdomen is divided into four quadrants:
 „ RUQ,LUQ,RLQ,LLQ
Observation:
Much information can be gathered from simply watching the patient and
looking at the abdomen. This requires complete exposure of the region in
question, which is accomplished as follows:
 Ask the patient to lie on a level examination table that is at a comfortable
height for both of you.
 Take a spare bed sheet and drape it over their lower body such that it just
covers the upper edge of their underwear (or so that it crosses the top of
the pubic region if they are completely undressed). This will allow you to
fully expose the abdomen while at the same time permitting the patient
to remain somewhat covered.
 The patient's hands should remain at their sides with their heads resting
on a pillow.
 Keep the room as warm as possible and make sure that the lighting is
adequate. By paying attention to these seemingly small details, you
create an environment that gives you the best possible chance of
performing an accurate examination.
While observing the patient, pay particular attention to:
 Appearance of the abdomen. Is it flat? Distended? If
enlarged, does this appear symmetric or are there distinct
protrusions, perhaps linked to underlying organomegaly? The
contours of the abdomen can be best appreciated by
standing at the foot of the table and looking up towards the
patient's head.
 Presence of surgical scars or other skin abnormalities.
 Patient's movement (or lack thereof). Those with peritonitis
(e.g. appendicitis) prefer to lie very still as any motion causes
further peritoneal irritation and pain. Contrary to this,
patients with kidney stones will frequently writhe on the
examination table, unable to find a comfortable position.
Various Causes of Abdominal Distension

Hepatomegaly Ascites
Obese abdomen

Markedly enlarged gall

bladder Umbilical Hernia

(labeled
"GB")
Auscultation:
 Compared to the cardiac and pulmonary exams, auscultation of the
abdomen has a relatively minor role.
 It is performed before percussion or palpation as vigorously touching the
abdomen may disturb the intestines, perhaps artificially altering their
activity and thus bowel sounds.
 Exam is made by gently placing the pre-warmed (accomplished by rubbing
the stethoscope against the front of your shirt)
What diaphragm
exactly on the abdomen
are you listening for and
and listening for 15 or 20 seconds. what is its significance? Three things
should be noted:
1. Are bowel sounds present?
2. If present, are they frequent or
sparse (i.e. quantity)?
3. What is the nature of the sounds (i.e.
Abdominal Auscultation quality)?
Percussion
The technique for percussion is the same as that used for the lung exam.
1. First, remember to rub your hands together and warm them up
before placing them on the patient.
2. Then, place your left hand firmly against the abdominal wall such that
only your middle finger is resting on the skin.
3. Strike the distal interphalangeal joint of your left middle finger 2 or 3
times with the tip of your right middle finger, using the previously
described floppy wrist action (see under lung exam).
There are two basic sounds which can be elicited:
4. Tympanitic (drum-like) sounds produced by percussing over air filled
structures.
5. Dull sounds that occur when a solid structure (e.g. liver) or fluid (e.g.
ascites) lies beneath the region being examined.
 Abdominal Percussion

What can you really expect to hear when percussing the normal abdomen?
The two solid organs which are percussable in the normal patient are the liver and
spleen. In most cases, the liver will be entirely covered by the ribs. Occasionally, an
edge may protrude a centimeter or two below the costal margin. The spleen is
smaller and is entirely protected by the ribs.
Liver
 The right upper quadrant of the abdomen is palpated and percussed to
estimate the size of the liver
 Enlarge liver may be seen in patients with chronic right sided heart failure
occuring secondary to chronic respiratory disease
 Hepatomegaly
- The liver increased in size
- The superior and inferior border of the liver are identified by percussion
-Normal: liver spans about 10cm at the midclavicular line
-Abnormal: more than 10cm.,considered enlarged
Spleen
 Speed percussion, as described in the pulmonary section, may also be
useful.
 Percussion of the spleen is more difficult as this structure is smaller and lies
quite laterally, resting in a hollow created by the left ribs.
 Splenomegaly
- The spleen increased in size
- When significantly enlarged, percussion in the left upper quadrant will
produce a dull tone.
Palpation:
 First warm your hands by rubbing them together before placing them on
the patient. The pads and tips (the most sensitive areas) of the index,
middle, and ring fingers are the examining surfaces used to locate the
edges of the liver and spleen as well as the deeper structures. You may use
either your right hand alone or both hands, with the left resting on top of
the right. Apply slow, steady pressure, avoiding any rapid/sharp movements
that are likely to startle the patient or cause discomfort.

Abdominal Palpation
Hooking Edge of the Liver
1. Start in the right upper quadrant, 10 centimeters below the rib margin in the
mid-clavicular line. This should insure that you are below the liver edge. In
general, it is easier to detect abnormal if you start in an area that you're sure
is normal.
2. Following this, repeat the examination of the same region but push a bit more
firmly so that you are interrogating the deeper aspects of the right upper
quadrant, particularly if the patient has a lot of subcutaneous fat. Pushing up
and in while the patient takes a deep breath may make it easier to feel the
liver edge as the downward movement of the diaphragm will bring the liver
towards your hand.
3. You can also try to "hook" the edge of the liver with your fingers. To utilize
this technique, flex the tips of the fingers of your right hand (claw-like). Then
push down in the right upper quadrant and pull upwards (towards the
patient's head) as you try to rake-up on the edge of the liver.
4. Place your right hand at the inferior and lateral border of the ribs, pushing
down as you push up from behind with your left hand.
5. Examine the left upper quadrant. The normal spleen in not palpable. When
enlarged, it tends to grow towards the pelvis and the umbilicus (i.e. both
down and across). Begin palpating near the belly button and move slowly
towards the ribs. Examine superficially and then more deeply. If the spleen is
very big, you may even be able to "bounce" it back and forth between your
hands. Splenomegaly is probably more difficult to appreciate then
hepatomegaly
Findings Commonly Associated With Advanced Liver Disease:

Chronic liver disease usually results from years of inflamation, which ultimately leads to
fibrosis and decline in function. Histologically, this is referred to as Cirrhosis.
 Hyperbilirubinemia: The diseased liver may be unable to conjugate or secrete bilirubin
appropriately. This can lead to
 Icterus - Yellow discoloration of the sclera.
 Jaundice - Yellow discoloration of the skin.
 Bilirubinuria - Golden-brown coloration of the urine.
 Ascites: Portal vein hypertension results from increased resistance to blood flow
through an inflamed and fibrotic liver. This can lead to ascites, accumulation of fluid in
the peritoneal cavity.
 Increased Systemic Estrogen Levels: The liver may become unable to process
particular hormones, leading to their peripheral conversion into estrogen. High levels
promote:
 Breast development (gynecomastia).
 Spider Angiomata - dilated arterioles most often visible on the skin of the upper
chest.
 Testicular atrophy.
 Lower Extremity Edema: Impaired synthesis of the protein alburmin leads to lower
intravascular oncotic pressure and resultant leakage of fluid into soft tissues. This is
particularly evident in the lower extremities.
 Varices: In the setting of portal hypertension, blood "finds" alternative pathways back
to the heart that do not pass through the liver.
 Icterus

Gynecomastia

Ascites

Jaundice

Spider

Edema
Examination of the Extremities
General Considerations:

The patient should be undressed and gowned as needed for this examination.
● Some portions of the examination may not be appropriate depending on
the clinical situation (performing range of motion on a fractured leg for
example).
● When taking a history for a chronic problem always inquire about past
injuries, past treatments, effect on function, and current symptoms.
● The cardinal signs of musculoskeletal disease are pain, redness
(erythema), swelling, increased warmth, deformity, and loss of function.
● Always begin with inspection, palpation and range of motion, regardless of
the region you are examining.
Inspection
1. Look for scars, rashes, or other lesions.
2. Look for asymmetry, deformity, or atrophy.
3. Always compare with the other side.
Palpation
4. Examine each major joint and muscle group in turn.
5. Identify any areas of tenderness.
6. Identify any areas of deformity.
7. Always compare with the other side.
Vascular:
Pulses
8. Check the radial pulses on both sides. If the radial pulse is absent or weak,
check the brachial pulses.
9. Check the posterior tibial and dorsalis pedis pulses on both sides. If these
pulses are absent or weak, check the popliteal and femoral pulses.
Capillary Refill
1. Press down firmly on the patient's finger or toe nail so it blanches.
2. Release the pressure and observe how long it takes the nail bed to "pink" up.
3. Capillary refill times greater than 2 to 3 seconds suggest peripheral vascular
disease, arterial blockage, heart failure, or shock.
Edema, Cyanosis, and Clubbing
4. Check for the presence of edema (swelling) of the feet and lower legs.
5. Check for the presence of cyanosis (blue color) of the feet or hands.
6. Check for the presence of clubbing of the fingers.
Peripheral skin temperature
 When the heart fails to circulate enough blood, compensatory vasoconstriction
in the extremities helps shunt blood to the vital organs
 Papation of the patient’s feet and hands may provide general information about
perfusion
 Cool extremitie usually indicate poor perfusion.

- Normal: extremity should be at least 2 degree celsus warmer than room

temperature
- Abnormal: less than 2 degree celsus difference, perfusion is reduced
Exam of Upper Extremities
The Hands:
 Appearance of hand and fingers: Any obvious deformity or
discoloration? Do they appear relatively red and well perfused or
white/mottled?
 Nail shape and color:

Paronychia:
Infection of skin
Nicotine adjacent to nail of
Staining middle finger

Onychomycosis:
Fungal Infection of the NailOnycholysis:
Separation of
Nail from
Underlying Bed,
often due to
onychomycosis
 Capillary refill: normal pink color should return in 2-3 seconds

Peripheral Vascular
Disease, Hand

 Temperature: Cool hands occur most commonly as a result of

exposure to a cold environment. However, this can also reflect
vascular insufficiency, vasospasm, or hypovolemia.
 Joint abnormalities, noting particularly if there is a

specific pattern or distribution.

Joint deformities secondary to rheumatoid arthritis
 Clubbing: Bulbous appearance of the distal phalanges of all fingers
along with concurrent loss of the normal angle between the nail base
and adjacent skin. This is most commonly associated with conditions
that cause chronic hypoxemia (e.g. severe emphysema), though it is
also associated with a number of other conditions. However, in general
it is neither common nor particularly sensitive for hypoxia, as most
hypoxic patients do not have clubbing.

 Cyanosis: A bluish discoloration visible at the nail bases in select

patient with severe hypoxemia or hypoperfusion. As with clubbing, it is
not at all sensitive for either of these conditions.
 Splinter Hemmorrhages: Short, thin, brown, linear streaks in
the nails of some patients (the minority) with endocarditis.
 Edema: While edema is a relatively common finding in the
lower extremity, it rarely occurs in the arms and hands. This is
because the lower extremities are exposed to greater
hydrostatic pressure due to their dependent position.
Examination of the Upper Extremities
The following focuses on the search for evidence of arterial and
venous insufficiency as well as edema. These are the most
common serious ailments which affect the lower extremities and
therefore merit the greatest attention.
The Femoral Region: As with examination of any other area of the
body, exposure is key. Socks, stockings, pants and skirts should all
be removed.
1. Begin by simply looking at the area in question, which is on
either side of the crease separating the leg from the groin
region. Make note of any discrete swellings, which might
represent adenopathy or a femoral hernia.
2. Palpate the area, feeling carefully for the femoral pulses as well
as for inguinal/femoral adenopathy (nodes which surround the
femoral artery and vein.... up to one cm in size are considered
non-pathologic). If you feel any lymph nodes, note if they are
firm or soft, fixed in position or freely mobile (fixed, firm nodes
are more worrisome for pathologic states).
3. The femoral pulse should be easily identifiable, located along
the crease midway between the pubic bone and the anterior
iliac crest. Use the tips of your 2nd, 3rd and 4th fingers. If there
4. A femoral hernia, if present, is located on the anterior thigh, medial to
the femoral artery. As it can be transient (i.e. the patient reports its
presence yet you find nothing on examination), investigation should include
observation as well as palpation while the patient performs a valsalva
maneuver, which may make a hernia more prominent
The Popliteal Region: Move down to the level of the knee
allowing it to remain slightly bent.
 Place your hands around the knee and push the tips of your fingers
into the popliteal fossa in an effort to feel the popliteal pulse. This
artery is covered by a lot of tissue and can be difficult to identify,
so you may need to push pretty hard. Even then, it may not be
palpable, which is not clinically important if you can still identify
the more distal pulses.
 Below The Knee: from the knee to the foot particular in:
1. Color

Chronic Arterial Insufficiency

Acute Arterial Insufficiency

Venous Insufficiency Cellulitis

Gangrene of Toes
2. Swelling of the leg

Assymetric Leg, Swelling

secondary to Deep Venous
Thrombosis in Right Leg

3. Nail growth

Onychomycosis
4. Skin

Venous Stasis Ulcer

5. The bottom of the foot and between the toes

Neuropathic Ulcer in Patient
with Diabetic Neuropathy

6. The depth of an ulcer

Clinical Osteomyelitis:
Deep ulcer which permits
passage of Q-tip to underlying
level of bone
Feel the skin, noting in particular:
1. Temperature
2. Edema
- Fluid frequently collects in the feet
Massive
and ankles due to the effects of gravity.
edema.
- Edema is commonly associated with venous
insufficiency, a blood return problem.
3. Capillary Refill: Push on the tip of the great toe or the nail bed until
blanching occurs.
4. Skin that is discolored from venous insufficiency blanches when
pushed and it generally takes more then a few seconds for the bluish
due to return.
5. Pain Paronychia:
Infection of the skin medial and inferior to nail of great toe. Image on the
right is post I&D
Distal Regin: Dorsalis Pedis (DP) Artery
 To identify the presence of arterial vascular disease.
 Located just lateral to the extensor tendon of the big toe, which
can be identified by asking the patient to flex their toe while
you provide resistance to this movement.
- Gently place the tips of your 2nd, 3rd and 4th fingers adjacent
to the tendon and try to feel the pulse.
- If you can't feel it, try moving your hand either
proximally/distally or more laterally and repeat.
- Common pitfalls include pushing too hard and/or mistaking
your own pulse for that of the patient. Palpating the patients
radial artery or your own carotid simultaneously with your free
hand can help sort this out.
Merci!