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Patient examination in the internal medicine
The patient examination covers three main fields: taking the patient’s case history, the
physical examination and based on the results of them, targeted laboratory tests and
examinations. Taking the case history is an important tool in this process.
During that, we not only collect the most important data about the patient and his disease, but
we also build the fundament of the confidential relationship that is required for treating the
patient. From the very first moment on, when the doctor meets the patient, we collect
impressions in the patient and his disease. We observe the stature, the state of development,
his/her biological age, motility, activity, his/her level of vigilance. We also judge the severity
of the illness.
Taking the patient’s case history is made up of the following superimposed parts:
1. Introduction, personal data
2. Getting to know the major complaints
3. Revealing the circumstances of the present illness
4. Revealing the past diseases, regularly taken medications, incidentally drug allergies
5. Taking the family history
6. Getting to know the personal and social circumstances
7. Surveillance of general and organ-related well-being
Physical examination
During the physical examination of the patients, four simple methods are used: inspection,
palpation, percussion and auscultation.
First, we observe the most important parameters regarding the state of the patient, i.e. the vital
parameters. We take the blood pressure, count the pulse rate and observe its rhythm, the
breathing excursions and the body temperature.
Then, from the top to the bottom, we examine all regions, organs and organ systems of the
human body.
First, we perform the examination of the head and neck region.
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We observe the shape of the skull, examine the hair, inspect and palpate the region covered
with hair, looking for present or past injuries or deformities of shape, and check for tenderness
of the skull.
From up to down, we observe the eyebrows, the palpebral and the periorbital region, and the
alterations that we found should also be palpated.
Then, we examine the eyes: we pull down the lower eyelid; observe its color, looking for
signs of symmetric or asymmetric inflammation or paleness. We observe the sclera, looking
for bright yellow discoloration. We examine and compare the pupils, regularity of their edge,
their position, wideness and using a light, the direct and consensual pupil reactions.
We judge the vision field and the eye movements.
Then, we inspect whether the cheeks, the nose back and the nose are intact or show any
lesions. We put special emphasis on the symmetry of the face, also checking out the facial
muscle movements.
We inspect the ears and the periauricular region on both sides, as well.
Then, we examine the mouth and the oral cavity. We observe the color of the lips, looking for
paleness, cyanosis or lesions. After opening the mouth, using also a spatula, we thoroughly
inspect the oral mucosa, the gingiva, color of the mucosa, looking for possible injuries,
bleedings or mucosal lesions. We inspect, whether teeth are intact or show lesions; the
pharyngeal marches, the palate and the tonsilles, as well as the uvula.
We observe the tongue, its color, brightness, the presence of fur, abnormalities of the shape
and its movements. We inspect and palpate the temporomandibular joint.
Moving from region to region, we continue with the examination of the lymph nodes. We
thoroughly palpate for the occipital, periauricular, submandibular, submental regions, the
lymph nodes on the neck in front of and behind the sternocleidomastoid muscle, the supraand infraclavicular, jugular, axillar and inguinal lymph nodes. If we find an enlarged lymph
nodes or lymph nodes, we judge its location, size, but also its count, consistency, tenderness,
mobility and skin lesions above or surrounding the lymph node.
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We inspect and palpate the thyroid gland both from forward, and also standing At the back of
the patient. We observe its size, symmetry, consistence, tenderness and its motility on
swallowing. We put special emphasis on finding nodules in it.
Then we continue with examination of the chest. We inspect the shape of the chest, its
anterioposterior and sagittal diameter and the ratio of them, symmetry and possible
deformities. We observe the breathing excursions of the chest, and whether some areas are
hypomotile.
We inspect and palpate along the vertebral column, judging its physiologic and pathologic
curvatures. Using our fist, we percuss the spinal processes, looking for tender areas. We also
examine the tenderness and muscle tone of the paravertebral areas. We palpate the skin and
the structures of the chest, looking for bone or muscle lesions, local tenderness.
We palpate the breasts in several positions of the arms. (Figure)
Then, we check out the pectoral or tactile fremitus. We put both palms at the back of the
patient, to a place uncovered by the scapula, ask the patient to say a word with diphthong
phrases (e.g. blue moon or ninety nine) loud, meanwhile we compare the two sides, if the fine
resonance led to the chest surface are symmetric, equal on both sides?
We continue with percussion of the chest. A basic rule is always to percuss in the intercostals
spaces, holding our finger parallel to the investigated, expected border.
The first part of the percussion of the chest is the topographic percussion, when we evaluate
the extension, the size of the lung and the borders of the diaphragm. First percuss for the socalled Krönig’s space from the shoulder muscles to medial, looking for air-containing areas.
Then, along the paravertebral line, moving from intercostal space to intercostal space, we
determine the borders of the diaphragm on both sides, this is where the resonant sound turns
dull. In the paravertebral line, this should be normally at the height of the 11th vertebra. Then
we investigate the chest excursions, in that we percuss in the intercostal space just below the
border, and check whether the dullness changes to resonance due to moving down of the
diaphragm. We look for the lung borders in some selected lines, i.e. the scapular line (the 10 th
intercostals space), the mid-axillary line (the 8th intercostal space), the medioclavicular line in
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the front (the 6th intercostal space) and eventually parasternally, where it shoud
physiologically be in the 4th intercostals space.
The second part of percussion of the chest is the comparative percussion, where we percuss in
identical points on the two sides of the chest, comparing the percussion sound, judging
alterations in air content of the lungs.
The possible findings are summarized in a table:
Percussion sounds
 Tympanic - pneumothorax
 Hyperresonant - emphysema
 Resonant – normal lung
 Dullness (relative dull) - pneumonia
 Absolute dullness - pleural fluid, pleural callus
As next, we investigate the breathing comparing two sides of the chest using our stethoscope.
We aim for the breathing sounds, the auscultability and proportion of in- and exspiration, and
look for abnormal sounds.
The most important physiological and abnormal sound are depicted in tables:
Breathing sounds:
 Alveolar
Vesicular
Bronchovesicular
Weakened sounds - emphysema, pleural fluid, pneumothorax, callus
 Bronchial
Physiologically: right side interscapular
Abnormal: anywhere else – may be sign of a pneumonia
Abnormal (adventitious) sounds
1. Extrapulmonal: pleural friction
2. Intrapulmonal:
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A. dry or bronchial sounds: wheezing, rhonchi (during in- and exspiration) – obstructive
pulmonary diseases
B. wet sounds or crackles (during in- and exspiration) – mucus in the airways
small crackles
middle crackles
coarse crackles – pulmonary edema
C. crepitation: only during inspiration – pneumonia
D. fibrotic crackles – pulmonary fibrosis
As next part of the physical examination, we examine the heart.
We observe signs of the state of circulation, color of the skin (paleness, cyanosis, plethora),
we examine its temperature, dryness or moisture using palpation.
We palpate the precordial area looking for thrills and the apical impulse, examining its
location and characteristics. The normal location of the apical impulse is on the left side, 2 cm
medial from the midclavicular line.
Then we percuss for the borders of the heart. Using stronger percussion, we percuss for the
relative, using a more superficial palpation, for the absolute dullness. As a first step, holding
our finger parallel to the expected diaphragm border, moving on the right side in the
midclavicular line from up to down, we check out the height of the diaphragm that is normally
found in the 6th intercostal space.
Then, turning our plessimeter finger perpendicularly, moving towards the sternum, we look
for the right border of the dullness of the skin. Physiologically, the dullness should not exceed
the right edge of the sternum.
Then we percuss for the upper border of the heart: moving on the left side, parasternally from
intercostal space to intercostal space. Physiologically the dullness indicating the upper border
should be found in the 3rd intercostal space.
Eventually, we percuss for the left border of the dullness of the heart: in the 5th intercostal
space, moving from the left mid-axillary line towards the sternum, holding our finger
vertically, we look for the border that is 2 cm medial from the midclavicular line.
The last part of the physical examination of the heart is auscultation: we auscultate above the
auscultation areas corresponding to the valves. (Figure)
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First, we auscultate above the apex and in the 4th intercostal space on the left for the mitral
area.
Then we auscultate for sounds coming from the aortic valve on the right side, in the 2nd
intercostal space, parasternally.
Then parasternallly, in the same height, but on the left side, we auscultate for the pulmonary
valve.
Eventually, on the right side, in the 4th intercostal space, parasternally we listen to the sound
of the tricuspid valve.
During the auscultation, we check out the 1st and 2nd heart sound, their loudness, their
proportion to each other, rhytmicity, clearness, and the potential additional sounds. In case we
hear a murmur, we judge the point of maximal intensity, the so-called punctum maximum,
that shows, which valve the murmur originates from. And also the location of the murmur
within the heart cycle (systolic or diastolic), that indicates, what kind of alteration of the valve
may have provoked the murmur. We also observe other characteristics of the murmur, namely
its loudness and the dynamics (for example crescendo, decrescendo). Eventually, we check
for whether the murmur is led from the location of the origin of the murmur towards the
direction of the blood stream.
The physical examination is continued with examination of the abdomen and the abdominal
organs. Correct positioning of the patient is important: the patient should lie in a flat, supine
position, we ask the patient to put his arms next to the trunk and to bend his knees.
First, we observe abnormalities in form; the level of the abdomen is compared to the level of
the thorax. We inspect potential skin lesions of the abdomen, operation scars, striae,
herniations, dilation of abdominal veins.
Then we auscultate above the abdomen using our stethoscope. First, we judge the bowel
sounds, their alterations reflect changes in peristaltics of the bowels, for example, in a
paralytic ileus we cannot hear any bowel sounds.
After auscultation of the bowel sounds, we also auscultate above the blood vessels, the renal
arteries and the iliac arteries.
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By suddenly pressing in the abdominal wall using our stethoscope or our another hand, we try
to provoke splashing, that may be heard physiologically above the stomach, in other regions
in case of an ileus.
We continue with the percussion. By percussing above the abdomen, we can evaluate the gascontent of the bowels.
Then we examine the dullness of the abdominal parenchymatous organs.
Percussing on the right side, above the chest, along the midclavicular line from up to down,
we should physiologically reach the upper border of the liver in the 6th intercostal space; the
lower edge of the organ can be found 6-12 cm more downwards, and it is indicated by the
presence of a tympanic percussion sound due to the air content of the bowels.
The dullness of the spleen can be found on the left side, in the midaxillary line, between 9th
and 11th intercostal spaces. Disappearance of the dullness of the liver and/or spleen may be an
important hint towards organ perforation in the abdomen.
We can percuss for the presence of a free abdominal fluid, as well.
We start at the uppermost point of the abdomen of the patient lying in a supine position,
moving radially, we look for the border of fluid in the abdominal cavity that is found where
the tympanic sound changes to dullness.
After having determined the border of the dullness in all directions, we ask the patient to turn
on his side and repeat the percussion. In case of a free abdominal fluid, we detect that the
dullness moved on the one side closer to the umbilicus, on the other side away from it.
Then the palpation of the abdomen and the abdominal organs comes. The proper position is of
most importance in this phase of the examination. As a general rule we can say that we should
palpate with warm hands and short fingernails, making slow motions, leaving the tender area
for the last, and continuously watching even the slightest movement of the face of the patient.
The palpation is performed in two parts: first the abdominal wall is palpated superficially
using circular movements; here we evaluate the muscle tone, looking for a circumscribed or
diffuse defense that can be an alarming sign of peritoneal irritation. As a second part of
superficial palpation, we look for lesions between the layers of the abdominal wall.
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Following, we perform the deep palpation of the abdomen, this way we are looking for a
palpable mass, a resistance and check for tenderness.
If we find a palpable mass, we describe the exact localization, size, shape, consistence,
tenderness and mobility.
Then we continue with palpation of the liver. We press on the abdominal wall of the patient
lying in a supine position in the right lower quadrant, then, while asking the patient to take a
deep breath, we look for the edge of the liver sliding underneath are hands. Moving couple of
centimeters upwards, we repeat the test, until we reach for the edge of the liver.
Physiologically, the liver should not exceed the edge of the right ribcage.
Using a similar method on the left side, we check for palpability of the spleen. The size of the
spleen should be evaluated not only in supine position, but also lying on the right side.
Physiologically, the spleen should not be palpable, either.
In case we find an enlarged liver or spleen, we evaluate its size, surface, consistence and
tenderness.
A possible enlarged kidney may be palpated by a so-called sliding palpation. We put one hand
underneath the waist of the patient, with the other hand, we press in the abdominal wall. The
patient is asked for repetitive maximal expirations, this way the two hands get closer to each
other. Then, lifting the waist, ballotting it, we can be able to palpate for the enlarged kidney.
The examination of the abdomen is finished in reasonable cases with the rectal digital
examination. (Figure) We inspect the perianal region, then we introduce our index finder with
glove and lubricator into the rectum and palpate for structures there. In the end, we also
evaluate the feces sticking to the glove.
The next part of the physical examination is the examination of peripheric blood vessels. For
that, we check out and compare the color and temperature of the four extremities, we look for
skin lesions (wounds, ulcers), we palpate the dorsal pedal artery, the posterior tibial artery, the
popliteal artery, the femoral artery, and on the upper extremity the radial, ulnar and cubital
arteries.
We palpate for the pulse of the carotid arteries and auscultate above them, looking for
murmurs.
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During the physical examination of the extremities, we compare their diameter, we observe
various veins, operation scars, ulcers, nails and movements of the patient.
On the lower extremity, by pressing in the skin above the tibia, we check out the type and
extent of swelling of the extremity.
The data on medical history, and data observed during the physical examination should be
collected, we out together the documentation of the patient, not only including the abnormal
findings. Then we make up a list of problems, and decide about necessary tests and
treatments.
After that we inform the patient on the results of the examination, the tests to be performed
and the suggested therapy.
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