The Respiratory System: History and Physical Assessment

Physiologic Function of the Lungs

Exchange respiratory gases Maintenance of acid-base balance

Primary Muscles of Respiration

Diaphragm External Intercostals

Accessory Muscles–Trapezius

–Sternocleidomastoid

–Abdominal Muscles

–Internal Intercostals

History Tobacco use Coughing Chest pain Dyspnea

History Orthopnea Paroxysmal nocturnal dyspnea (PND) Activity tolerance Recurrent pneumonia or bronchitis Pollutants (asbestos, coal dust, chemicals,

etc.) Passive smoking R/O risk for TB

History Review family history Pneumonia or influenza vaccine Date of last TB test

Physical Exam General assessment

* Inspect facial expression

* Posture configuration of chest (AP -diameter should be 1/3-1/2 transverse diameter)

* Respiratory rate and pattern

* Inspect hands for clubbing

Physical Exam Sitting position for posterior and

lateral May sit or supine for anterior Undressed from waist up NEVER listen through clothing!!!!!!

Normal Adult

Scoliosis

Kyphosis

Barrel Chest

Pectus Excavatum

Pectus Carinatum

Landmarks of Clinical Importance

Sternum Clavicle Suprasternal notch Manubriosternal angle Midsternal line Midclavicular lines Anterior axillary lines Midaxillary lines Posterior axillary lines Scapular lines Vertebral line

Posterior Chest Palpate for any tenderness or

abnormalities Measure posterior chest excursion

*Should be symmetrical

Posterior Chest Palpate for tactile fremitus

*Vibration of the chest wall during speech

At each position ask the patient to say “99”

If difficulty feeling, ask the patient to speak louder and deeper

Tactile Fremitus Decreased fremitus is caused from

excess air (emphysema, pneumothorax, atelectasis).

Increased fremitus is caused by the presence of fluid or a mass.

Posterior Chest Percussion- determine whether the lung

tissue is air filled, fluid filled, or solid. Sounds of percussion * Resonant * Dull * Tympanic * Flat * Hyperresonant

Posterior Chest Measure diaphragmatic excursion

*Normal should be 3-5cm

*The diaphragm is normally higher on the right.

*Diaphragmatic descent may be limited by pulmonary lesions, abdominal

lesions or pain.

Posterior Chest Auscultation

*Use diaphragm of stethoscope

Types of Breath Sounds Bronchial: loud, high pitched. Bronchovesicular: medium pitch. Vesicular: soft, low pitched.

Additional Tests Abnormalities assessed in tactile fremitus,

percussion, or auscultation Bronchophony- In same location as breath

sounds say “99” or “eee”.

*Normally sounds are muffled. Whispered pectoriloquy- In same location

as breath sounds whisper “99”.

*Whispered voice should be faint.

Lateral Chest Same as posterior chest, may perform

along with posterior chest.

Anterior Chest Inspection Chest excursion Evaluate tactile fremitus

Anterior Chest Percussion Auscultation

Adventitious Breath Sounds

Crackles:

– Fine Crackles

– Medium Crackles

– Coarse Crackles

Adventitious Breath Sounds

Rhonchi Wheezes Pleural Friction Rub

Order of the Physical Exam

Posterior Chest:– Inspection

- Palpation

- Chest Excursion

- Tactile Fremitus

- Percussion

- Diaphragmatic Excursion

- Auscultation

Order of the Physical Exam

Lateral Chest:

– Inspection

– Palpation

– Tactile Fremitus

– Percussion

– Auscultation

Order of the Physical Exam

Anterior Chest:

– Inspection

– Palpation

– Chest Excursion

– Tactile Fremitus

– Percussion

– Auscultation

Adventitious Breath Sounds

Rhonchi: Primarily heard over the trachea and bronchi.

Adventitious Breath Sound

Wheezes

Adventitious Breath Sounds

Pleural Friction Rub