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Once you have done your initial introductions and examination from the end of the bed described in the examinations page you can then move onto more specific examination.
Now we can approach the patient and start to take a good close look at them. As with both abdominal and cardiovascular examination we always start with the patients hands. As well as just looking one can also tell a lot from the feel of those hands:
We then move our examination up the arm. I always make a point of looking at the arm as I move up so that I do not forget anything.
At this stage we need to check the radial pulse and we are checking it for presence, rate, rhythm and volume. A very tachycardic patient may be septic, or it could just be the drugs which we give them which are making their heart beat faster.
A patient with a bounding pulse may be showing early signs of carbon dioxide retention. As with all systems when you have two of something you should always compare and contrast. So you should check the other hand to see if there are any differences and you should compare the radial pulses on both sides.
Moving further up the arm as you go higher this is a visual reminder to check the blood pressure. The heart and lungs are interconnected and what affects one can very well affect the other. The patient in crashing pulmonary oedema for example may very well have a very high blood pressure that may need some controlling with nitrates.
We then move up further and into the patients’ neck. Here you will want to check and observe a number of things:
The patients face is where we turn our attention to next.
The patient’s chest then becomes the area we examine next. A visual inspection is what we do first. The respiratory, cardiovascular and abdominal systems are all examined using the process of inspection, palpation, percussion and auscultation. So we first need to simply look at the chest wall for any indications of any problems we need to be aware of:
Then we can palpate the chest once we have done our inspection.
This is a fairly simple process when doing an examination of the chest. You are mainly checking for equal chest expansion. One simply puts ones hands on the chest with one on each side and ask the patient to take a deep breath in. You then note whether the chest seems to rise and expand equally.
At this point you can also try to ascertain if there is reduced tactile vocal fremitis. If you suspect an area of some consolidation then when you put a hand over it and ask the patient to say 99 for example you are more likely to feel them say it than over a non consolidated area.
Percussion of the lung fields comes next.
Correct percussion technique is not difficult but it might take some practice before you feel completely confident when doing it.
The non-dominant hand is placed on the patient’s chest. Then all put the 2nd finger are lifted off the chest. The entire length of the 2nd finger should be kept in contact with the chest.
It is important to keep the other fingers off the chest wall so that you do not dampen any sound you may elicit.
The 2nd finger of the dominant hand then acts as a hammer to strike the distal phalangeal joint of the other hands 2ndfinger.
You strike this with the tip of the finger which will then create a nice sound for you to compare all over the chest wall.
It is important to Percuss over the entire chest wall from top to bottom, comparing both sides, noting any dullness or hyper-resonance as you go. Be aware that you may get dullness where there are other structures involved such as over the liver for example.
Once this is done it is time to put your stethoscope over the patient’s chest. When doing so make sure that you use the diaphragm and that you press firmly.
You should leave a slight imprint on the patient’s chest when you do so. Again make sure that you cover the whole of the chest and be aware of which lobe you are likely to be listening too when you move about. Because the lobe divisions are oblique you need to be aware that from the front on the left side you are mainly listening to the upper lobe.
From the back on the left side, at the top of the shoulders you are still listening mainly to the upper lobe but the rest of the left side at the back will be the lower lobe. Much the same on the right side but here you have three lobes to think about.
On the front the upper part is mainly upper lobe whilst the lower part of the chest will be the middle lobe. It is only when you move around to the back that you will begin to encounter the lower lobe at the lower end of the right side of the back.
So what are you listening for?
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