Professional Documents
Culture Documents
1.
GENERAL INSPECTION
1.
The patient should be undressed to the waist and women should wear a gown a have a towel
or some clothing to cover their breast when front of the chest is not being examined
I would like you to undress yourself until your waist level for examination. (Saya mahu
anda untuk menanggalkan baju sehingga paras pinggang anda untuk pemeriksaan)
Start the respiratory examination by inspecting the respiratory signs including calculating
the respiratory rate as standing at the right of the patient
Then, stand at the right side foot of the patient and do comments for the following
components
Physical attitude
Mental status
State of the
patient
Position of the
patient
Conscious level
Orientation
Respiratory sign
Pattern of
breathing
The patient is
comfortable / is not comfortable,
not in pain / in pain,
and
without any abnormal movement / with abnormal movements.
He is
sitting over the edge of the bed/sitting of a chair
He is alert and conscious /
Patient is in confusion
He is not alert and conscious
during severe carbon
dioxide retention
He is well orientated to time, place and person / He is not
well orientated to time, place and person
Respiration rhythm
Dyspnea
Character of
cough
respiratory rate is
Sputum
Hoarseness
25
16 breaths per
COPD
Chronic bronchitis
Pneumonia
Bronchiectasis
Chest infection
Asthma
Carcinoma of bronchus
Left ventricular failure
Interstitial lung disease
Usage of ACE inhibitor drugs
Problem with the upper airway like pharynx and
larynx
Pertussis infection
There is no hoarseness in
patients voice / There is
hoarseness in patients
voice.
asthma
General
appearance
Built
The patient is
Height
Weight
Tall / average in
height / short
and
Thin (loss in
weight) / average
in weight / obese
He looks
Built
Hydration and
nutrition status
Look
The patient
looks normal
is ill looking / looks toxic
Gross
deformity
Patient is well hydrated with good nutritional status / The hydration status
and nutritional status of the patient looks fair / The hydration and nutritional
status of the patient is poor.
*anything which are visible during general inspection should be mentioned, for example leg
swelling, hernia, masses anywhere on the body and many more.
Attachment
(mention only the
Name tag
Intravenous
attachments of
the patient)
cannulation
Nasal prong /
Oxygen mask
Urinary catheter
Surgical tube to
drain fluid
Instrument to
monitor vital sign
Insulin sliding
scale
POP cast
Metered dose
inhaler
Sputum mug
Medications