1. General inspection - cachexic, tachypnoea?, barreal shapped chest, inhalers devices or oxygen around
2. Observe the breath in and out - pursed lips breathing
3. Examine hand - tar stain, palmar erythema, flapping tremor
4. Pulse - Bounding pulse
5. Respiratory rate
6. Eyes - suffused conjunctiva
7. Mouth - Central cyanosis, pursed lips breathing
8. Neck - JVP
9. Trachea - Reduced cricosternal distance (less than 3 fingers), central?
10. Inspect the chest again front and side - barrel shape, hyperinflated chest (vertical > horizontal expansion
11. Feel Apex beat - displaced, or difficult to appreciate - emphysematous
12. Parasternal heaves, P2? cor pulmonale
13. Chest expansion - 3 places
14. Percussion - resonance? dull? Apical, 2 middle, 1 axilla
15.Auscultation - Breath sounds reduced or equal? Bronchial breathing? Prolonged expiratory phase, Inspiratory coarse crackles, Expiratory wheeze.
16. Vocal resonance
17. Swing to the back
18. Feel for lymph nodes
19. Expansion again
20. Percuss - apical, 2 middle, 1 axilla
22. Vocal resonance
23. Pedal oedema
I would like to end my examination by checking Mr ABC's temperature at the observation chart, doing a PF and looking into the sputum pot.
Mr ABC has the appearance of plethora, flushed looking and purse lips breathing. He is tachypneic at rest, with respiratory rate of 24 breaths a minute and usage of accesory muscles and intercostal recession.
On peripheral examination, there is finger clubbing, palmar erythema and nicotine stain. I found signs of CO2 retention with bounding pulse and asterixis. On face and neck examination, he has suffused conjunctiva, but no jaundice or central cyanosis. His tracheal is centrally located.
Moving on the the chest, there is no scars noted. The chest looks hyperinflated with appearance of barrel chest. My chest findings are: Reduced chest expansion bilaterally throughout, resonance percussion, reduced air entry on the right hemithorax and coarse pan-inspiratory crepitations on the left lower zone which is altered by coughing. Vocal resounce is unremarkable. There is expiratory wheeze all over the lung fields with prolonged expiratory phase.
There is no pedal oedema and JVP is not raised and there is no loud P2 or parasternal heaves.
Cervical lymph nodes are not palpable.
In summary, Mr ABC has emphysema on the right lung and left lower zone bronchiectasis with underlying COPD secondary to cigarette smoking. He is in respiratory failure. In the context of chronic lung disease, there is no signs to suggest cor pulmonale.