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 fat? Chest wall disease, Obstructive sleep apnoea Is the patient thin? COPD, cancer Are there signs of respiratory distress? Breathlessness, nasal flaring, pursed lip breathing, tracheal tug, accessory muscle usage, cyanosis. Do you know what the accessory muscles are? Inspiratory: Sternocleidomastoids, scalenes, pectoralis major, pectoralis minor, serratus anterior. Expiration: abdominal muscles (external oblique, internal oblique, rectus abdominalis) Is there a relevent spot diagnosis? E.g Horners syndrome
Is there clubbing (Shamroths sign), can you give a differential if there is?, tar staining, cyanosis, C02 retention flap/Asterix, ?B2-agonist tremor (could it be a benign essential tremor?), palpate wrists for tenderness (hypertrophic pulmonary osteoarthropathy – from lung ca). Take the radial pulse and RR, listen to and watch pt. breathing, paradoxical breathing? (due to flattened diaphragm in emphysema), prolonged expiratory phase? (obstructive disease).
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