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Is this the same on both sides. Is there evidence of hyperinflation. Are scars present from surgery. Is there evidence of chest wall deformity. Feel the chest to confirm equality of movement, and check for chest wall crepitus and surgical emphysema. Is there evidence of chest wall tenderness or pain.

Is any pain positional, or worsened on inspiration (as, for example, in pleurisy). Listen to the chest. Percuss the learning in psychology and posterior chest wall bilaterally at the top, middle, and bottom of the back.

Is the percussion note normal, dull, or hyper-resonant. Auscultate the chest at the same locations and in the axillae while the patient breaths in and out of an open mouth. Listen for the sounds of bronchial breathing, wheeze, or crackles. Tip If learning in psychology is uncertain if a percussion note is dull or normal, compare with the result bit dog percussing learning in psychology the liver (lower ribs on learning in psychology right).

The percussion note will sound dull as the liver is a solid organ. Cipro 500 Tactile vocal fremitus and vocal resonance are increased in consolidation and decreased in pleural effusion and pneumothorax.

If the adult patient complains of symptoms of a respiratory tract infection, undertake an ENT examination. Look in the mouth to examine for tonsullar and pharyngeal inflammation, and feel for enlargement of the lymph nodes in the neck.

Pitfall Do not attempt to examine learning in psychology upper airway of a child with respiratory distress learning in psychology with stridor or drooling.

These findings may be indicative of epiglottitis and attempts to examine the mouth and throat may provoke complete airway obstruction. In all patients with sudden onset of learning in psychology of breath and in the absence of other findings strongly suggestive of a respiratory problem, undertake an examination of the cardiovascular system (see articles two and three of this series). Box 7 Pertinent features of the respiratory examination GeneralDiagnosis is often straightforward with a typical history and findings.

For example, the patient presenting with wheeze and tachypnoea may state that they have asthma. The skill is in determining the severity of the condition. Few patients die as a result of the misdiagnosis of asthma but significant numbers die because professionals or patients under-estimate the severity of an episode. Differential diagnosis can also be very difficult, the classic situation being in distinguishing between an exacerbation of COPD and cardiogenic pulmonary oedema.

This may be made simpler by the use of b-naturetic peptide (BNP) estimations. This has recently been made available as a near-patient test and may become increasingly common learning in psychology the out of hospital setting. Table 1 summarises the pointers in history and examination in patients with asthma that help to gauge the severity of an episode.

These can be triggered by a number of factors but a viral infection is the most frequent. Diagnosis is often simple but it is the assessment of the severity of the condition learning in psychology needs skill. Learning in psychology main differential diagnosis is of cardiogenic pulmonary oedema (LVF). A pneumothorax is an uncommon reason for a severe sudden exacerbation of COPD.

Signs of exhaustion, inability to expectorate, or CO2 retention are the main worrying features indicating a severe episode. Oxygen treatment learning in psychology these patients should be titrated against the SPo2 (controlled oxygen therapy-see the North-West Oxygen Group guidelines).

The patient is older and usually has a history of ischaemic heart disease although this may be the first indication of heart problems. Acute MI is often a precipitating factor. Severe shortness of breath, white frothy sputum, tachypnoea, and tachycardia are common.

Such patients need to be transported to hospital, sitting upright if possible. Immediate learning in psychology consists of buccal nitrates (providing the blood pressure is not low), oxygen, and intravenous opioids (table 4). The criteria for home treatment varies from country to country (table 5).

Table 6 describes additional findings determined from the secondary survey that will suggest the need for hospital admission. All patients with a first episode of pulmonary oedema or an acute exacerbation of a chronic problem should be admitted to hospital for further investigation learning in psychology treatment.

Findings from secondary survey suggesting need for hospital admissionSpontaneous pneumothorax is most common in tall, thin, fit young learning in psychology (see table 6). It is an uncommon complication of asthma and COPD. There are some rarer causes but these will be very uncommon in the community setting. If a pneumothorax is suspected, the patient will need to be referred to hospital learning in psychology a radiograph and further evaluation.

Half of all patients suffering for pulmonary guys sex will develop this condition while in hospital or long term care.

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