Right side of patient
Wash hands
‘May I now examine you? Are you in any pain?’

General Inspection

Look around bed for: medication, oxygen, insulin, chest leads, walking aids, medical-alert bracelet.
Does the patient look: well, breathless, well nourished. Any recognisable syndrome, how is the patient’s complexion?

Exposure
Resp: Strip to the waist; 45 sitting upright

Hands

‘May I have a look at your hands?’
Inspect dorsal and palmar aspects noting colour, skin texture, deformities and feel for temperature or sweating.

Look for tar-staining, finger clubbing

NAILS: koilonychias (spoon-shaped nail in iron deficiency), onycholysis (destruction), Beau’s lines (chronic disease), Mee’s lines (renal failure), Muehrcke’s lines (hypoalbuminaemia), pitting (psoriasis/alopecia) and capillary nailbed pulsation (Quinke’s sign of aortic regurge).

WRISTS: for tenderness (hypertrophic pulmonary osteoarthropathy – lung ca), asterixis (CO2 retention flap, liver failure).
Test for CO2 retention flap. ‘Can you stretch out your arms and cock your wrists.’ While patient is doing this note the respiratory rate (count breaths for 15 seconds and x4)

Face
Mouth: Looking for central cyanosis

Praecordium
Inspect
Praecordium for scars (look in apex) and ask patient to identify, implantable devices, colour, surface vessels, muscular deformity, breathing.

Palpate
Chest expansion (both hands, thumbs meet in midline below nipples – reduced expansion implies pathology on that side)

Percussion
Percuss over clavicle, pec, nipple and axilla areas. Comparing sides.
Resonance = air in lungs e.g. pneumothorax, emphysema.
Resonance = consolidation, collapse, fluid. (Stony Dull percussion note in pleural effusion)

Auscultation
‘Take deep breaths in and out through your mouth.’
Listen with diaphragm over same areas percussed
Whispering petriloquy ‘Whisper 99’ (increased in consolidation)

Breathe sounds – Normally vesicular. Bronchial breathing indicates consolidation. Reduced/Absent breathe sounds indicate pleural effusion, pneumothorax or collapse.

Sit patient forward
‘I’d like to do the same on your back. Could you sit forward.’

Back
Inspect
Back for deformity, scars.

Palpate
Feel for lymph nodes
‘I’m going to feel for the nodes in your neck.’
Feel spine
‘Any pain in your back?’
Chest expansion
‘Breathe in and out.’
Press for sacral oedema

Percuss
Tap at three points comparing each side

Auscultate
‘Take deep breaths in and out through your mouth.’
Whispering petriloquy ‘Whisper 99’ (increased in consolidation)

Thank patient
Dress patient