Chapter 2:	Patient Observation
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Observation of the patient, which is the initial phase of the physical examination, actually begins during the interview and needs to be conducted meticulously. Be aware that there will inevitably be some overlap of the information gleaned during the interview, observation, and subsequent hands-on physical examination. All three yield valuable information.

The observation should begin with the RCP’s glance around the patient’s room that often can tell you a lot about the clinical situation. Some of the more revealing items to look for include: the presence of isolation signs and supplies, and various monitors or equipment chest tubes.

The RCP should observe the rate, rhythm and frequency of the patient’s respiration during exercise and at rest. It is also important to observe the shape of the patient’s chest, and take note of whether or not the patient needs to use accessory muscles of respiration. Abnormalities in the formations of the bony thorax and spine (such as kyphosis, pectus excavatum, scoliosis, or lordosis) should also be noted.

It is important to take note the patient’s bed. For example, if the bed is in the trendelenberg position, it can be suggestive of the existence of hypotension. A bed locked in an upright position or one that has an unusual number of pillows can suggest orthopnea resulting from CHF/pulmonary edema.

The patient’s position in the bed can also be revealing. For example, patients with severe lung disease tend to avoid lying flat in bed because they generally have difficulty breathing in that position.

Many patients who are experiencing excess work of breathing brace their upper torso by resting their arms on the bedside table or holding on to the side rails in order to get increased leverage for the accessory muscles of respiration. Air trapping in COPD patients flattens their diaphragm, so they can frequently be seen in this position because they rely on the upper chest muscles to facilitate breathing.