The Respiratory System: History and Physical Assessment.
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Transcript of The Respiratory System: History and Physical Assessment.
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