Introduce, explain, glance from end of bed: dyspnoea, lip
pursing, cyanosis, accessory muscle usage, hyperexpanded
Say "Could you hold out your hands straight out please,
and cock up
your wrists," and inspect for a flapping tremor of CO2 retention for
5-10s (you will never see it in an exam).
Inspect nails for clubbing and nicotine stains.
Press on the nails for capillary refill time. Say, "could you turn your
hands over" and feel for temperature.
Record the radial pulse for 15s, and then the respiratory
rate for 15s.
Say "would you like me to measure the blood pressure?"
Look in the eyes. Pull down
one
lid for conjunctival pallor. Look in the mouth for central cyanosis
Neck
Say "could you turn your head to the left" and look to see
if the venous pressure is raised
Carotid pulse with finger tips
Feel from behind for lymph nodes. This might preferably
done when they
are leaning forward just before you examine the back of their chest.
Say "this might feel a bit uncomfortable" and then
using 3 fingers feel for tracheal deviation (one finger either side of
trachea, one finger on trachea). Then tracheal tug: find number of
fingers between cricoid and suprasternal notch.
Chest
Expose the praecordium. If this is a women you will be
expected to remove her bra.
Inspect
for scars,
assymmetry, recession.
Palpate
the apex beat
(see cvs exam for the proper technique).
Palpate
for symmetry of
expansion (this is often done half-heartedly - use this
technique to actually elicit something). First say "can you take a
breath in and blow it all out." Once blown out put your hands thumbs
together around the lower part of their chest (the same way you would
throttle somebody's neck, if you were a murderer). Get them to take
another deep breath and observe if your thumbs move apart
symmetrically.
Percuss
starting at
clavicles and then 3 levels down, comparing sides as you
go. Percuss axillae (they may need to lift their arms up)
Auscultate
.
Say "when I put this on you can you take a deep breath in and out
through your mouth." Start in supraclavicular fossa using bell, then
switch to diaphragm and go down 3 levels comparing sides. Auscultate
axillae.
Back of chest
Say "would you mind leaning forward."
Essentially the same: inspect, expansion, percuss,
auscultate.
Other
Expose press on their shins for at least 3s for ankle
oedema.
"I would like to"
Measure the peak flow: if there is one available you
must
do this
This
is Mr Smith. He is tachypnoeic at rest. He has nicotine staining of the
fingers and accessory muscle usage. There is no flapping tremor of the
hands.
He has tracheal tug and an equal hyperexpanded chest.
Percussion is hyperresonant. Auscultation reveals
prolonged expiratory phase and expiratory ronchi.
My diagnosis is chronic obstructive airways disease.
