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    General Inspection:

    • Introduction/consent/indications/wash hands/name & age of patient/asks patient for sites of pain before commencing:

    • Performs a general inspection:

      • General appearance:

        1. Student comments on whether patient is comfortable or distressed?

          Comments on signs of respiratory distress: RR, accessory muscle use, dyspnoea, subcostal recession, intercostal recession, nasal flaring, expiratory grunting ( PEEP) & difficulty speaking or feeding

      • Inspection of hands:

        1. Assesses temperature (warm peripheries associated with CO2 retention)

          Assesses for clubbing (chronic suppurative lung disease e.g. CF, peripheral cyanosis & palmar creases), nicotine staining

          Assesses for a flapping tremor associated with CO2 retention

      • Radial Pulse: For 30 seconds ideally. Comments on whether pulse is bounding (CO2 retention)

      • Respiratory rate:

      • Offers to perform BP:

      • Offers to perform JVP and hepato-jugular reflex (absent in SVC obstruction)

      • Inspection of the eyes:

        1. Anaemia (pale lower lid conjunctiva), corneal arcus (hyperlipidaemia) & an obvious Horner's syndrome: Ptosis (drooping of eyelid due to interruption to sympathetic system supply to Muller's muscle), miosis (papillary constriction), anhidrosis and enopthalmos (sunken eyes)

      • Inspection of the mouth:

        1. Assesses hydration

          Comments on any evident central cyanosis (O2 saturation <90%)

          Comments on any anaemic signs

      • Inspection of the chest:

        1. Comments on any obvious findings: Hyper-expansion (barrel shape in asthma), pectus excavatum (benign)/ carinatum (severe asthma), Harrison's sulcus (poor asthma control due to diaphragmatic tug), symmetry of chest movements & scars


    • Lymph nodes in neck:

      1. Palpates posterior/anterior auricular, mandibular, mental, cervical, supra/infraclavicular, suboccipital lymph nodes

    • Assesses position of the trachea:

      1. Checking central, assess with less pressure and by placing thumb & middle finger to lateral areas, and index to assess location
        Assess for a tracheal tug (approximately 2 fingers separate suprasternal notch and thyroid cartilage). This is associated with hyperexpansion in COPD

    • Palpates apex beat for mediastinal shift:

    • Palpates for a right ventricular heave:

    • Palpates for chest expansion:

      1. Measures max chest expansion with a tape measure/ hands posteriorly & anteriorly. Normally 4-5cm

    • Palpates for tactile fremitis:

      1. Transmitted sounds palpated due to consolidation acting as transmission medium. Performed with ulnar border of hand

    Chest Percussion:
    • Comments on whether resonant (normal), hyper-resonant (tension pneumothorax), dull (consolidation) or stony dull (pleural effusion)

    Chest auscultation:

    • Asks patient to cough initially

    • Comments on following comparing to both sides:

      1. Breath sounds: Normal or reduced (effusions, asthma, pneumothorax, COPD or pleural thickening)

        Vesicular (normal breathing, with a sinusoidal pattern of sound) or bronchial (sawtooth sound, with abrupt uprising and termination). Bronchial breathing is heard over a plural effusion, consolidation or areas of fibrosis

        Added sounds: Wheeze (air through narrow airways, and is monophonic i.e. one obstruction due to tumour or polyphonic as in asthma), pleural rub (inflammation causing two pleural surfaces to rub), stridor or crackles (re-opening of small airways during inspiration. They are fine in distal occlusion such as pulmonary oedema or coarse in proximal occlusion such as bronciectasis. Early crackles are associated with small airways disease, and late with alveolar disease)

        Vocal resonance: Present (consolidation) or absent

        Whispering pectoriloquy: Present or absent

        Above comments must be made based on the zones of the lung: Upper (ribs 1-2), middle (ribs 2-4) and lower (remaining ribs)

        Student offers to perform ENT examination: Otoscopy & throat inspection

        Student assesses medial/ lateral malleolus for evidence of right sided heart failure

    Thanks patient & documents findings in the notes:

Author: Mr Adnan Darr MBCHB, BSc, MSc, MRCS  | Speciality: Examination  | Date Added: 11/10/2011


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