TO START |
W2I2P4E | Wash your hands Wear appropriate PPE Introduce yourself and check patient’s Identity Permission: “May I examine your chest / heart and blood vessels?” Privacy: Ensure curtains to the bay are closed Pain: “Are you in any pain at all?” Position: Patient at 45o Exposure: to waist (women can keep bra on)
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INSPECTION |
Surroundings | Monitoring – ECG, pulse oximeter, catheter, drains bag Treatments – O2 (flow rate & method of delivery), IV access, chest drain (examine contents, is it swinging or bubbling?), antibiotics, inhalers, nebulisers, non-invasive ventilation Paraphernalia – cigarettes, sputum pot, inhaler, mobility aids
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Patient | General appearance – well/unwell, comfortable at rest, alertness & conscious level, cachexia (malignancy, severe heart failure), obesity Colour – cyanosis, pallor (shock, anaemia) Signs of respiratory distress – use of accessory muscles, pursed lips, flared nostrils, tachypnoea, tripod position Breathing – audible stridor (inspiratory) or wheeze (expiratory) Coughing – can be valuable to ask patient to cough, does it sound wet or dry?
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UPPER PERIPHERIES |
Hands (5Cs) | Clubbing (bronchiectasis, pulmonary fibrosis, malignancy) Colour – look for peripheral cyanosis Cigarette tar stains - tar causes the discolouration, not nicotine Cancer (Pancoast’s tumour → wasting of small muscles of the hand, best detected in the thenar eminence and 1stdorsal interosseous) CO2 retention flap (asterixis) – 3Hz flap when the wrists are cocked back and extended (salbutamol-induced tremor is finer and faster) Note thin skin, bruises/purpura which could be due to steroid therapy (COPD, asthma, ILD)
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Arms | Radial pulse – Rate, Rhythm Respiratory Rate - count over 15s while palpating radial pulse then x4 (12-20 is normal)
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Face | Conjunctival Pallor (severe anaemia) Horner’s syndrome (miosis, anhidrosis, ptosis - Pancoast tumour) Facial plethora (smokers, superior vena cava obstruction)
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Mouth | |
Neck | Carotid pulse: character (bounding - CO2 retention)) and volume (thready – shock). Jugular Venous Pressure (JVP): start looking for the JVP at the insertion of sternocleidomastoid at the clavicle and manubrium. Work upwards and look for an upwards biphasic flicker. Elevated in right heart failure, fluid overload, tension pneumothorax, severe asthma. Tracheal Deviation - warn patient it may be uncomfortable Lymphadenopathy - assess with patient sitting forwards and palpating from behind. Can wait until examining the back, but don’t forget!
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CHEST |
Start at the front: Inspect, Palpate, Percuss, Auscultate Then repeat from the back. Check for lymphadenopathy while patient is sitting forward if you haven’t already |
Inspect | Ask patient to place hands on hips Scars - thoracotomy (pneumonectomy), chest drains in axillae Skin Changes - radiotherapy tattoos, telangiectasia Shape - pectus excavatum/carinatum, barrel, scoliosis, kyphosis Breathing Pattern - Seesaw (airway obstruction), flail chest (rib fractures)
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Palpate | Expansion - AP and laterally (normally >5cm, check for symmetry) Apex Beat - lateral displacement (mediastinal shift, cardiomegaly) RV Heave - (cor pulmonale 2° to pulmonary hypertension)
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Percuss | |
Auscultate | Listen with diaphragm, ask the patient to breathe in and out normally through their mouth. Move in ‘S’ shape for comparison between sides At each area, listen for: Breath sounds - intensity and quality (vesicular or bronchial) Added sounds - crackles; fine or coarse (pneumonia, pulmonary oedema), wheeze (obstruction), rub (pneumonia, infarct, pleurisy) Vocal resonance - “Say 99 every time I place my stethoscope on your back” (increased in consolidation, reduced in effusion)
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LOWER PERIPHERIES |
Back | |
Legs | Pitting oedema - palpate over bony prominences. If present must find limit (heart failure, fluid overload) Unilateral calf swelling/tenderness/redness (DVT) Erythema nodosum (granulomatous disease e.g. TB, sarcoidosis)
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CLOSURE |
Closure | |
To Complete (SPOTX) | |
