Clinical Skilllllllllllllll
Clinical Skilllllllllllllll
Clinical Skilllllllllllllll
This is essentially an examination of the patient’s lungs; however it is a complex examination which
also includes examination of other parts of the body including the hands, face and neck.
The respiratory examination aims to pick up on any respiratory (breathing) pathology that may be
causing a patient’s symptoms e.g. shortness of breath, cough, wheeze etc. Common conditions
include chest infections, asthma and chronic obstructive pulmonary disease (COPD). This
examination is performed on every patient that is admitted to hospital and regularly in clinics and
general practice.
Like most major examination stations this follows the usual procedure of inspect, palpate, percuss,
auscultate (look, feel, tap, listen). It is an essential skill to master and is often examined in OSCEs.
Subject steps
1. Begin by washing your hands, introduce yourself and clarify the patient’s identity. Explain
what you would like to do and gain the patient’s consent.
2. The patient should be sitting up and exposed from the waist up. Make a general
observation of the patient. Check whether they are comfortable at rest, do they
look tachypnoeic, are they using accessory muscles, are there any obvious abnormalities
of the chest. Also check for any clues around the bed such as inhalers, oxygen masks, or
cigarettes.
Observe the patient from the end of the bed
3. Move to the hands. Hot, pink peripheries may be a sign of carbon dioxide retention. Look
for any signs of clubbing or nicotine staining. Ask the patient to extend their arms and
cock their wrists to 90 degrees. Observe the hands in this position for 30 seconds; a
coarse flap may also be a sign of carbon dioxide retention.
4. At the wrist you should take the patient’s pulse. A bounding pulse may indicate carbon
dioxide retention. After you have taken the pulse it is advisable to keep your hands in the
same position and subtly count the patient’s respiration rate. This helps to keep it as
natural as possible.
6. Look for any use of accessory muscles such as the sternocleidomastoid muscle. Also
palpate for the left supraclavicular node (Virchow’s Node). This drains the thoracic duct
so an enlarged node (Troisier’s Sign) may suggest metastatic cancer e.g. lung or
abdominal.
7. The examination now moves onto the chest. Take time to observe the chest looking for
any abnormalities such as changes in rib cage shape, or scars. Remember these may be
in the axillae or on the back.
8. Now palpate the chest. Firstly feel between the heads of the two clavicles for the trachea.
If it is deviated, it may suggest a tumour or pneumothorax.
9. Feel for chest expansion. Place your hands firmly on the chest wall with your thumbs
meeting in the midline. Ask the patient to take a deep breath in and note the distance
your thumbs move apart. Normally this should be at least 5 centimetres. You should
measure this at the top and bottom of the lungs as well as on the back.
10. Perform percussion on both sides, comparing similar areas on both sides. You should
start by tapping on the clavicle which gives an indication of the resonance in the apex.
Then percuss normally for the entire lung fields. Hyper-resonance may suggest a
collapsed lung where as hypo-resonance or dullness suggests consolidation such as in
infection, effusion or a tumour. Be sure to perform this on the back as well.
11. Check for tactile vocal fremitus. Place the medial edge of your hand on the chest and ask
the patient to say “99″. Do this with your hand in the upper, middle and lower areas of
both lungs. This again gives a suggestion of the constitution of the tissue deep to your
hand.
12. Finally, auscultate. Do this in all areas of both lungs and on front and back comparing the
sides to each other. Listen for any reduced breathe sounds, or added sounds such as
crackles, wheeze, pleural rub or rhonchi.
Auscultate left lung
13. Whilst using the stethoscope, ask the patient to again say “99″ whilst listening in all areas
– this is a more reliable test than the one described earlier.
14. Finish by examining the lymph nodes in the head and neck. Start under the chin with the
submental nodes, move along to the submandibular then to the back of the head at the
occipital nodes. Next palpate the pre- and post- auricular nodes. Move down the cervical
chain and onto the supraclavicular nodes.
15. Thank your patient and allow them to dress. Wash your hands and report your findings to
your examiner.
Sample Lung Sounds (courtesy of Dr. Michael Wilkes, MD-- UC Davis and UCLA
Schools of Medicine)
Crackles
Wheeze
Stridor
Normal Voice E
Egophony
BLOOD PRESSURE
where:
is cardiac output
is systemic vascular resistance
is central venous pressure and usually small enough to be neglected in this formula
Equation: MAP = [(2 x diastolic)+systolic] / 3
Diastole counts twice as much as systole because 2/3 of the cardiac cycle is
spent in diastole. An MAP of about 60 is necessary to perfuse coronary
arteries, brain, kidneys.
Usual range: 70-110. 80 Y, IN CHILD 40-600t he blood pressure depends on cardiac
output (a strong heart leads to a high cardiac output) and total peripheral resistance (artherosclerosis and
stress increases the resistance). A high pressure leads to higher stresses of the arterial wall and increase
the risk of thrombosis, embolism and rupture. A high blood pressure is also an indication that the vessles
are unhealthy.
CONSCIOUSNESS
4 = spontaneous
3 = to voice
2 = to pain
1 = none
5 = normal conversation
4 = disoriented conversation
3 = words, but not coherent
2 = no words, only sounds
1 = none
6 = normal
5 = localized to pain
4 = withdraws to pain
3 = decorticate posture (an abnormal posture that can include rigidity, clenched
fists, legs held straight out, and arms bent inward toward the body with the wrists
and fingers bend and held on the chest)
2 = decerebrate (an abnormal posture that can include rigidity, arms and legs held
straight out, toes pointed downward, head and neck arched backwards)
1 = none
Clinicians use this scale to rate the best eye opening response, the best verbal response,
and the best motor response an individual makes. The final GCS score or grade is the sum
of these numbers.
Every brain injury is different, but generally, brain injury is classified as:
Mild brain injuries can result in temporary or permanent neurological symptoms and a
neuro-imaging tests such as CT scan or MRI may or may not show evidence of any damage.
Suhu manusia yang sehat, yang diukur di ketiak, berkisar 36-37 derajat
Celsius pada siang hari.
Suhu di bawah normal lebih rendah dari 36,2 ° C dan berhubungan dengan
metabolisme terkendali. Hal ini dapat diamati pada orang tua, pada penyakit
cachexia penyebab kronis (tumor), dihipopituitarisme, hipotiroidisme, setelah
perdarahan yang berlebihan, dan shock.
Suhu Subfebrile tidak melebihi 38 ° C, melainkan menyertai infeksi fokal (tonsillitis
kronis atau sinusitis, infeksi saluran kencing, adnexitis).
Demam (piretik, state demam) ditandai dengan peningkatan suhu tubuh di atas 38 °
C. Kondisi dengan suhu berkisar 40-41 ° C disebuthiperpireksia .
Demam terjadi pada radang, penyakit menular, penyakit sistemik, dan pada
tumor tertentu (limfoma, tumor Grawitz s). Bentuk kurva suhu beruang fitur
khas pada penyakit tertentu. Sebelumnya, fitur tersebut seharusnya cukup
penting. Pengenalan antibiotik ke dalam praktek klinis telah berubah
beberapa mantan fitur khas. Hanya untuk kelengkapan, kita menambahkan
gambaran dari jenis suhu.
consciousness
Continua Febris ditandai dengan fluktuasi suhu dalam kisaran 1 ° C selama periode
24 jam (typhus abdominalis, paratifoid, pneumonia croupous,erisipelas).
Febris remittens - fluktuasi harian melebihi rentang 1 ° C, suhu tidak kembali ke nilai
normal (penyakit menular).
Intermittens Febris (suhu septik) - suhu cepat menimbulkan sampai 39 ° C,
dengan cepat turun di bawah 37 ° C, dalam 24 jam perbedaan maksimum dan suhu
minimum lebih besar dari 1 ° C (sepsis, misalnya kolangitis, urosepsis, infeksi
endokarditis).
Febris recurrens - pergantian demam dan periode apyretic berbagai durasi.
Febris undulans - periode membesarkan dan jatuh suhu bergantian dengan periode
apyretic (limfoma perut, brucellosis).
Efemera Febris - demam satu hari ini disebabkan oleh kemajuan ringan infeksi
pernafasan, melalui transfusi darah, atau oleh aplikasi intravena obat-obatan tertentu.
Febris hectica - tahan lama suhu intermiten, sering terjadi pada TB
Appearance rhythm