The Purple Book

Chest examination

• In the community setting, the chest is usually examined in the context of chronic cardiac or respiratory disorders, including Heart Failure (HF) and Chronic Obstructive Pulmonary Disease (COPD)
• there will be times when examination will required to assess stability or progress of those conditions or some other acute episode which has caused deterioration. The examination then will not be limited to the chest.

• does the patient look acutely well or unwell?
• is the patient alert, orientated or drowsy and confused?
• Comfortable at rest or in pain? is the pain new?

Signs of respiratory distress:

• Dyspnoea/ tachypnoea
• Tripod posture - bracing posture
• Use of accessory muscles - look around the neck
• Pursed lip breathing
• Flared nostrils, intercostal/ subcostal recession
• inability to perform PEFR

Chest auscultation

• air entry equally on R & L? Inability to hear breath sounds is a bad sign only if the patient is in difficulty. If the patient is comfortable and you can't hear adequate air entry, check stethoscope or that the patient is compliant with your exam
• localised sounds?
• added crackles/creps
• wheeze - lack of wheeze in someone who is struggling to breath is a bad sign

Peripheral signs

• check RR, HR and BP and elevated Jugular Venous Pressure (JVP) for signs of failure
• presence of cyanosis?
• leg swelling - pitting oedema (of HF) vs non-pitting oedema (lymphoedema) for signs suggestive of DVT or cellulitis