What are the key components of a thorough physical exam for the skin, cardiovascular (CV), and pulmonary systems, including normal assessments?

Comprehensive Physical Examination Documentation for Skin, Cardiovascular, and Pulmonary Systems

Skin Examination

A thorough skin examination is essential for identifying both primary dermatological conditions and cutaneous manifestations of systemic diseases, particularly cardiovascular disorders. 1

General Inspection

• Overall skin color and pigmentation
• Hydration status
• Temperature (warm, cool, or cold)
• Presence of diaphoresis/sweating
• Integrity of the skin surface

Specific Findings to Document

• Presence or absence of:
  • Cyanosis (central or peripheral)
  • Pallor
  • Jaundice
  • Erythema
  • Rashes or lesions (document morphology, distribution, color)
  • Petechiae or purpura
  • Ulcerations (note location, size, depth, appearance of wound bed)
  • Edema (document location and pitting vs. non-pitting)

Skin Appendages

• Hair distribution pattern (note any abnormal loss or growth)
• Nail examination:
  • Color
  • Capillary refill time (normal < 3 seconds)
  • Clubbing
  • Splinter hemorrhages
  • Koilonychia (spoon nails)

Vascular Findings

• Presence of telangiectasias
• Spider angiomas
• Venous patterns
• Trophic changes (distal hair loss, hypertrophic nails) 1
• Intertriginous areas (assess for maceration, fungal infections) 1

Cardiovascular Examination

Vital Signs

• Blood pressure (measure in both arms if aortic dissection is suspected) 1
• Heart rate and rhythm
• Temperature
• Respiratory rate

Inspection

• Jugular venous pressure and pulsations (measured at 45° angle)
• Visible pulsations or heaves
• Chest wall deformities

Palpation

• Point of maximal impulse (PMI) location and character
• Thrills or heaves
• Palpation of the abdomen for aortic pulsation and maximal diameter 1

Auscultation

• Heart sounds:
  • S1 and S2 (document intensity as normal, increased, or decreased)
  • Presence of S3 or S4 gallops (note S3 suggests LV dysfunction) 1
  • Murmurs (document location, timing, intensity [grade 1-6], pitch, radiation, and quality)
  • Rubs (pericardial friction rub suggests pericarditis) 1

Peripheral Vascular Examination

• Pulse assessment at all sites: 1
  • Brachial
  • Radial
  • Ulnar
  • Femoral
  • Popliteal
  • Dorsalis pedis
  • Posterior tibial
• Document pulse intensity using standardized scale: 1
  • 0: Absent
  • 1: Diminished
  • 2: Normal
  • 3: Bounding
• Auscultation for bruits:
  • Carotid arteries
  • Abdominal aorta
  • Renal arteries
  • Femoral arteries 1
• Allen's test (when hand perfusion assessment is needed) 1

Pulmonary Examination

Inspection

• Respiratory rate and pattern
• Use of accessory muscles
• Chest wall symmetry
• Intercostal retractions
• Abdominal paradoxical breathing

Palpation

• Tactile fremitus
• Chest wall tenderness
• Subcutaneous emphysema
• Tracheal position (midline or deviated)

Percussion

• Resonance (normal, hyperresonant, or dull)
• Diaphragmatic excursion 1

Auscultation

• Breath sounds:
  • Normal vesicular breath sounds
  • Bronchial breathing
  • Decreased or absent breath sounds
• Adventitious sounds:
  • Crackles/rales (note location and timing - early or late inspiratory)
  • Wheezes (inspiratory or expiratory)
  • Rhonchi
  • Pleural friction rub
• Vocal resonance:
  • Bronchophony
  • Egophony
  • Whispered pectoriloquy

Respiratory Assessment

• Document signs of respiratory distress:
  • Bluish discoloration of face, lips, or nails
  • Abnormal respiratory rate and effort
  • Cough
  • Sensation of dyspnea
  • Restlessness and discomfort 1

Integration of Findings

Normal assessment findings should be documented as follows:

Normal Skin Examination

• Skin warm, dry, and intact without rashes, lesions, or abnormal pigmentation
• No cyanosis, jaundice, or pallor
• Capillary refill < 3 seconds in all extremities
• No edema, ulcerations, or trophic changes

Normal Cardiovascular Examination

• Regular rate and rhythm without murmurs, gallops, or rubs
• PMI at 5th intercostal space, midclavicular line
• No jugular venous distention
• Pulses 2+ and symmetric throughout
• No bruits over major vessels
• No edema or signs of decreased perfusion

Normal Pulmonary Examination

• Respirations unlabored with normal rate and depth
• Chest expansion symmetric
• Clear to auscultation bilaterally with good air entry
• No adventitious sounds
• Normal vocal resonance
• No use of accessory muscles

Important Clinical Considerations

• Pulse examination alone has limited sensitivity and specificity and should be supplemented with objective vascular testing when abnormalities are suspected 1
• Physical examination findings suggestive of severe peripheral arterial disease include distal hair loss, trophic skin changes, and hypertrophic nails 1
• The presence of rales, S3 gallop, or acute mitral regurgitation suggests left ventricular dysfunction and higher likelihood of severe coronary artery disease 1
• Patients with evidence of bruits or pulse deficits suggesting extracardiac vascular disease have a higher likelihood of significant coronary artery disease 1
• Pulse oximetry should be interpreted in the context of a complete assessment, with awareness of its limitations, particularly in patients with darker skin pigmentation 1