Читать книгу Respiratory Medicine - Stephen J. Bourke - Страница 58

Look for clubbing, tar staining or features of rheumatoid arthritis. Signs of CO₂ retention include peripheral vasodilation and asterixis: a flapping tremor detected by asking the patient to spread their fingers, cock their wrists back and close their eyes. CO₂ retention dulls proprioception and the hands tend to drift forward, particularly when the eyes are closed. Eventually, an awareness that the hands are no longer in position leads to a sudden corrective movement. In understanding the underlying mechanism of this sign, it should be clear why a doctor holding the patient’s hands in place (as many do to ‘feel’ for asterixis) will always miss it. Count the pulse rate and note any abnormalities in rhythm (e.g. atrial fibrillation) or character (e.g. a bounding pulse of carbon dioxide retention).

Count the respiratory rate over a period of at least 30 seconds. The respiratory rate is best counted surreptitiously, perhaps whilst feeling the pulse, as patients tend to breathe faster if they are aware that a doctor is focusing on their breathing. The respiratory rate is an incredibly easy observation to make and is a highly sensitive index of physiological derangement (as such, it is an integral part of all early‐warning systems in hospital), yet it is all too frequently missed. Do it. Do it properly.