Examination

Examination

1. Initial things to do

   • Wash Hands
   • Introduce yourself & gain consent
   • Position the patient and ask about exposure
   • Inspection
     • Is the patient well/ unwell?
     • Do they have a walking aid?
     • Are they nil by mouth?
     • Are there any medications around the bed?

2. Outside of chest wall

   • HANDS
     • Nails
       • Splinter haemorrhages
         • Present with infective endocarditis
       • Clubbing
       • Tar Staining
       • koilonychia
         • Present with iron deficiency anaemia
       • leukonychia
         • Present with hypoalbuminaemIa
     • Hands
       • Palmar erythema
         • Seen in liver failure
       • Janeway lesions & Osler nodes
         • Osler nodes on the fingers and painful
         • Janeway lesions- palms, painless
       • Dupuytren's contracture
         • fixed flexion due to fibrosis
           • seen in alcoholic liver disease
       • Tremors
         • Hepatic flap
         • CO2 flap
   • ARMS
     • Wrist
       • Radial pulse
         • Volume
         • Rhythm
           • Regular
           • Irregular
             • If so, state would investigate to see how is irregular
         • Rate
           • Measure over 15 or 30 secs
         • Character
           • Is it a bounding pulse
         • RR @ same time
         • Radio-radial delay
           • Offer radio-femoral
         • Collapsing pulse
           • Indicates AORTIC REGURGE
     • Blood pressure
   • FACE
     • Eyes
       • Jaundice
       • Ptosis and miosis
         • Horners syndrome
           • Damage to sympathetic trunk
           • Miosis, ptosis, anhydrosis (decreased sweating)
       • Corneal arcus
       • Xanthelasma
         • Hyperlipidaemia
       • Pallor in conjunctiva
         • Anaemia
     • Mouth
       • Cyanosis
         • Peripheral
           • Lips
           • Fingers
         • Central
           • Under the tongue
       • Poor dental hygene
         • Risk factor for infective endocarditis
       • Oral candida
         • can get with Excess salbutamol
       • Ulcers
         • Can be present in Crohns disease
       • Check the dentures
       • Glossitis
     • Neck
       • JVP
       • Any visible lumps and bumps/ lymph nodes
       • Carotid pulse
         • Better assessment of volume
       • Cricothyroid distance
         • Abnormal if >3fingers
       • Tracheal deviation
         • Tell pt will be uncomfortable but should be painless
         • eg will be deviated in tension pneumothorax

3. Chest Wall

   • Anterior chest wall
     • Palpation
       • Heaves & Thrills
         • feel heart (eg due to hypertrophy)
         • Palpable murmor
         • Place hands in z shape
       • feel for apex beat
         • 5th intercostal space in midclavicular line
       • chest expansion
     • Percussion
       • tap clavicle without finger underneath
       • work way down, compare like with like
       • 4-6 places
     • Auscultation
       • All Patients Take Money
         • auscultate for all 4 heat valves
       • Left lateral Position
         • Mitral stenosis/ regurge
       • Sit forwards, breath out and hold out, listen on left sternal edge for aortic regurge
       • Breath sounds
         • ask to take a deep breath through open mouth
       • vocal resonance
         • decreased with consolidation
   • Posterior chest wall
     • sit with legs over side of the bed
       • can do lymph exam here
     • Palpation
       • chest expansions
         • in 2 or 3 locations
     • Percussion
       • go with the shape of the ribs, not going over scapula
       • 6-8 places, remember the axilla
     • Auscultation
   • get appropriate exposure
   • inspection
     • Scars
     • Chest deformaties
       • eg barrel chest
     • Spider Naevi
       • (>5 significant) – chronic liver disease
     • Symmetrical chest expansion
     • Gynecomastia
       • chronic liver disease
       • Some drugs

4. Abdomen

   • Inspection
     • Scars
     • Distension
     • Obvious masses
   • Palpation
     • Superficial
       • Tenderness
     • Deep
       • masses
     • Be on level of pt
     • The liver
       • Start @ RIF work up
       • Ask to breath in, put hand in place, pt breath out
     • The spleen
       • Start in RIF work diagonally across
     • Ballot the kidneys
     • Aorta
   • Percussion
     • For the liver
     • For the spleen
     • Shifting dullness
       • looks for ascities
     • for the bladder
   • Auscultation
     • Bowel sounds
     • Renal Bruits