A comprehensive clinical examination is the basis for selecting further diagnostic steps:
- General physical examination – including blood pressure, pulse, body weight, height; further:
- Inspection (viewing).
- Of the skin, mucous membranes, and sclerae (white part of the eye) [cold sweatiness?]
- Gait (fluid, limping).
- Body or joint posture (upright, bent, gentle posture).
- Thorax [due todifferential diagnoses:
- Rib fracture (rib fracture) – symptoms: bruise marks, hematomas, pain related to breathing and movement.
- Rib contusion – symptoms: possible bruise marks, hematomas, respiratory and movement-dependent pain]
- Auscultation (listening) of the heart [due todifferential diagnoses:
- Aortic stenosis – obstruction (narrowing) of the outflow tract of the left ventricle.
- Pericardial tamponade – constriction of the heart by the pericardium.
- Hypertrophic cardiomyopathy – weakness of the heart muscle with enlargement of the heart and a tendency to severe arrhythmias, especially under stress.
- Pulmonary embolism – occlusion of one or more pulmonary vessels by a thrombus (blood clot).
- Myocardial infarction (heart attack)
- Pericardial effusion – accumulation of fluid in the pericardium.
- Pericarditis (inflammation of the pericardium); friction noises over the heart?]
- Examination of the lungs
- Auscultation of the lungs [due todifferential diagnoses:
- Bronchial asthma
- Bronchitis – inflammation of the bronchi.
- Bronchial carcinoma (lung cancer)
- Foreign body aspiration – inhalation of foreign bodies.
- Mediastinitis – inflammation in the mediastinum (space in the chest located between the lungs).
- Pleurisy (sicca) (pleurisy) [rubbing sounds over the lungs?]
- Pneumonia (pneumonia)
- Pulmonary hypertension (pulmonary hypertension)
- Pneumothorax – lung collapse further complicated by a valve mechanism]
- Bronchophony (checking the transmission of high-frequency sounds; the patient is asked to pronounce the word “66” several times in a pointed voice while the doctor listens to the lungs)[increased sound conduction due to pulmonary infiltration/compaction of lung tissue (e.g. e.g. in pneumonia) the consequence is, the number “66” is better understood on the diseased side than on the healthy side; in case of decreased sound conduction (attenuated or absent: e.g. in pleural effusion, pneumothorax, emphysema). The result is, the number “66” is barely audible to absent over the diseased part of the lung, because the high-frequency sounds are strongly attenuated]
- Percussion (tapping) of the lungs [e.g., in emphysema; box tone in pneumothorax]
- Vocal fremitus (checking the conduction of low frequencies; the patient is asked to pronounce the word “99” several times in a low voice while the physician places his hands on the patient’s chest or back)[increased sound conduction due to pulmonary infiltration/compaction of lung tissue (e. e.g. in pneumonia) the consequence is, the number “99” is better understood on the diseased side than on the healthy side; in case of reduced sound conduction (attenuated: e.g. atelectasis, pleural rind; strongly attenuated or absent: in case of pleural effusion, pneumothorax, pulmonary emphysema). The result is, the number “99” is barely audible to absent over the diseased part of the lung, because the low-frequency sounds are strongly attenuated]
- Auscultation of the lungs [due todifferential diagnoses:
- Palpation (palpation) of the abdomen (abdomen) etc. [ Pressure pain?, release pain?] [due todifferential diagnoses:
- Cholangitis (inflammation of the bile duct).
- Cholelithiasis (gallstones)
- Cholecystitis (gallbladder inflammation)
- Pancreatitis (inflammation of the pancreas)
- Ulcus ventriculi (stomach ulcer)]
- Examination of the extremities
- Inspection [pallor?, redness?, edema (water retention)?]
- Elicitation of pulse status’ (radial artery, femoral artery, posterior tibial artery, dorsalis pedis artery).
- Inspection (viewing).
- Neurological examination [due todifferential diagnosis:
- Cervical disc lesions – disc damage in the cervical spine]
- Orthopedic examination [due todifferential diagnoses:
- Chest wall tumors, unspecified
- Costochondritis – inflammation of the joints where the ribs and sternum articulate (inflammation of the cartilage of the ribs).
- Fibromyalgia (fibromyalgia syndrome) – syndrome that can lead to chronic pain (at least 3 months) in several regions of the body.
- Costochondritis – inflammation of the rib cartilage.
- Muscular overexertion
- Myositis – inflammation of the muscles.
- Rib fracture (rib fracture)
- Shoulder joint arthritis (inflammation of the joint)
- Shoulder joint bursitis (bursitis).
- Tietze syndrome (synonyms: chondroosteopathia costalis, Tietze’s disease) – rare idiopathic chondropathy of the costal cartilages at the base of the sternum (painful sternal attachments of the 2nd and 3rd ribs), associated with pain and swelling in the anterior thorax (chest) region
- Thoracic wall syndrome – pain in the chest caused by muscular and skeletal changes.
- Cervical disc lesions – disc damage in the cervical spine]
- Psychiatric examination [due todifferential diagnoses:
- Anxiety disorders
- Depression
- Mental illnesses such as anxiety disorders with panic attacks]
Criteria of a vital threat to the patient*
Repeated testing of a:
- Disturbance of consciousness
- Severe blood pressure dysregulation (RR ≤ 90 mmHg systolic or ≥ 220 mmHg).
- Tachycardia or bradycardia (heart rate > 100 or < 60/min).
- Respiratory insufficiency (SpO2 < 90%).
- Centralization, cold sweating
- Refractory pain
* If ≥ 1 criterion, a vital threat to the patient is possible! See also determination of Wells score for clinical probability of pulmonary embolism under “Pulmonary Embolism/Physical Examination“. Square brackets [ ] indicate possible pathologic (pathological) physical findings.
