WIPER and General examination
In an examination the mnemonic WIPER may serve as a reminder to wash your hands, introduce yourself, gain permission, expose the patient and reposition them as appropriate for the examination about to be performed. Simultaenously you should carry out a general examination noting the patients appearance, condition, and any clues from the environment. This forms the beginning of your mental account of the patient and can be remembered as ACC. See General Examination and Observations for more detail. The standard format that follows is always inspection, palpation, percussion, auscultation, and contemplation (Osler, Canadian turn of 19C physician, father of modern medicine). Additionally it is helpful to carry out the examination routine in a set sequence for example general, hands, neck, face, then specific, in this case, the chest wall. Finish by carrying out, or listing, relevent further clinical examinations and investigations, and presenting your findings. N.B. It’s a good idea to aim to be able to define, explain, and suggest a differential for any finding that you report.
Is the patient appear fat? Is there peripheral wasting? Is the patient thin? Malnourished, IBD, EtOH etc Is the patient jaundice? This is the cardinal feature of liver disease. Is the patient anaemic? GI bleeding. Cyanosed? E.g Hepatopulmonary syndrome. Is there digital clubbing? (GI causes), Oedematous? Chronic liver disease, Lymphadenopathy? e.g Virchows node/Trossieus sign? Are there signs of chronic liver disease?
Is there clubbing (Shamroths sign), koilonychia, peripheral stigmata of liver disease (leukonychia, dupuytren’s contracture, palmar erythema, liver flap), thenar eminence wasting or guttering.
Is the JVP elevated (cor pulmonale?) is there cervical lymphadenopathy (or better to do later from behind).
Is there conjunctival pallor (anaemia could make you SOB), does the patient have a plethoric facies (COPD can make you polycythamic), horners syndrome, mouth – central cyanosis, oral thrush (inhaled steroid use).
Chest wall, anterior and posterior
Is the chest symmetrical? Is there deformity? Are there any scars - look under arms, and at the back later too - why?
Trachea, apex beat, chest expansion, tactile vocal fremitus ’99’ or ``toy boat`` or ``neun und neunzig`` :-)
Include clavicles and axilla.
Any crackles, bronchial breathing, pleural rub, wheeze? Vocal resonance (if you forgot tactile vocal fremitus or prefer it).
Either do these things and/or say ”To complete my examination I would….``
Sacral oedema, ankle oedema, signs of DVT (calfs soft and non-tender), forced expiratory time (normal less than 6s), PEFR (peak flow), sputum pot.
Simple tests: peak flow, spirometry, urine dipstix, glucose, sputum cultures, pulse oximetry, ABG
Blood tests: Fbc, U&E’s, Ca, blood cultures, inflammatory markers
Imaging: CXR, bronchoscopy, pulmonary angiography, doppler legs