Washes hands.
Introduces self.
&
Asks Permission to examine the patient.
"Hi, my name is __________, I'm a final year medical student. Would it be alright for me to listen to your heart? Thank you."
Expose
&
Reposition
"I would like to have the patient at 45 degrees and exposed from the waist up.
Is it alright if I put you at 45 degrees? And are you fine to be undressed from the waist up? Thank you so much."
General Inspection
Bedside -
"I'm looking around the bed for any
- ECG leads,
- O2 therapy,
- or medication, for example, GTN spray."
The Patient -
"I'm looking at the patient to see
- if they look ill,
- are they SOB at rest,
- is there any cyanosis?
- Are they overweight or cachectic?
- Is there any obvious genetic syndrome, for example, Marfan's?"
Hands -
"Do you have any pain in your hands at all? May I have a look and feel of them?
I'm initially assessing for
- the temperature
- and hydration - are the hands particularly sweaty or clammy?
At the nails I'm testing
- the cap refill
- and looking for splinter haemorrhages.
At the sides of the fingers I'll inspect for
- signs of clubbing
- or tar staining.
I am then looking at the palms and finger pulps for
- Janeway lesions
- or Osler's nodes."
Wrist -
"At the patient's wrist
- I'm feeling the radial pulse to assess its rate and rhythm."
Upper Arm -
"At the antecubital fossa
- I'm palpating the brachial pulse, to assess rate, rhythm and character.
- I would at this point also like to take the patient's blood pressure.
Do you have any pain in your arm or shoulder? If it's alright, I'm just going to pull your arm up, relax - it shouldn't hurt.
- I'm testing for the presence of a collapsing pulse."
Neck -
"I'm just to feel your neck now.
- At the neck I am palpating the carotid pulse to assess the rate, rhythm and character.
Can you look to your left, and rest your head against the pillow/my hand?
- I'm assessing the JVP to see if it's raised, and moves with respiration.
Eyes -
"Can you look at the ceiling for me? I'm just going to pull down your lower lid, if you don't mind.
I'm looking at the
- sclera to assess for any sign of jaundice,
- and I'm looking to see any paleness of the conjunctiva.
And look straight ahead now.
I'm looking at the
- iris for corneal arcus.
- I am looking around eyes for xanthelasma."
Cheeks -
"I am looking at the cheeks for mitral facies."
Mouth -
"Can you open your mouth for me?
I am looking at
- the lips for peripheral cyanosis
- I am looking at the soft palate
- and assessing the dentition.
Can you raise your tongue to the roof of your mouth?
I am looking
- under the tongue for signs of central cyanosis.
You can relax your mouth now."
CHEST
Inspection -
"I'm looking at the chest for
- any scars,
- pacemakers,
- abnormal chest movements or shapes,
- and whether there are any visible pulsations.
- I can also check their leg to see if I suspect vein graft surgery."
Palpation -
"Do you have pain in your chest? If it's fine I'm just going to have a feel of your chest. Can you lean to the left for me?
- I am palpating the apex beat.
- I am also palpating for the presence of heaves or thrills."
Auscultation -
"I'm just going to have a listen now - you can breathe normally.
- I am listening at the 4 areas, with both the bell and the diaphragm of the stethoscope.
Can you breathe in for me and hold your breath. Ok, thank you, now can you breathe out for me and hold your breath. Now breath normally. Can you sit up and lean forward for me? Can you lean towards you left-hand side for me?
If there is an abnormal sound I am assessing
- the time,
- the site and radiation (either at the carotids or the axilla),
- the loudness and pitch,
- and the relationship to respiration and posture.
Can you hold your breath for me?
- I am also listening at the carotids for any evidence of bruits.
You can breath normally now.
Can you lean forward for me?
- I am listening for evidence of basal crackles.
- I am also checking for sacral oedema.
Ok, you can lean back on the bed and relax. Thank you very much _______, I'm all done - do you need any help putting your clothes back on?
To finish off the exam I'd like to examine
- the peripheral pulses,
- palpate the lower limbs for peripheral oedema,
- record an ECG,
- do a urine dipstick
- and if relevant - check the legs for scars from vein grafts, and examine the abdomen, particularly the liver if I suspect right heart failure.
Thank you again."
The ''And finally..." can be remembered handily by
DOPE as in "the person who writes this blog is dope... and for some reason I'm using slang from the 90s."
Dipstick
Oedema
Peripheral Pulses
ECG
I thank you.
Take a bow. Take a bow.
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