Patients with lung disease often complain of the following symptoms: dyspnea/shortness of breath, cough, sputum production, fatigue, exercise intolerance, chest tightness or chest pain. A thorough history and physical exam is required to identify other signs and symptoms to lead to a diagnosis.
The respiratory history draws on standard components of the history
along with standard HPI questions, ask about:
ask about it, regardless of cough
quantity - teaspoons, tablespoons, 1/2 cup
ask especially about prior illnesses, including:
ask about travels
CH2OPD2 mnemonic (Community, Home, Hobbies, Occupation, Personal habits,
Diet and Drugs)
To examine the back, have the person sitting, with arms crossed to move the scapulae out of the way. The front of the chest can be examined with the person sitting or lying down.
Respiratory rates decrease with age. The are most accurately measured with the patient asleep. Infants and young children can be evaluated abdominally; older children and adults with direct measurement of chest movement.
Normal rates are as follows (breaths/min):
Other aspects of the respiratory exam are as follows:
position of trachea
Percussion is one of the most important techniques, establishing whether tissues are fluid-filled, air-filled, or solid.
Measure descent of diaphragm, normally 5-6 cm in adults.
Dullness is heard over the scapula, liver, heart, and diapragm. It can also be caused by consolidation, fluid, pleural effusion, or pleural thickening.
Hyperresonance can be heard with a hyperinflated chest, ie with astma or COPD.
Areas of tenderness: fractured rib, inflamed pleura. give a squeeze AP and laterally to elicit.
chest expansion: place thumbs at level of 10th ribs. placing the hands on the sides is most sensitive.
tactile fremitus: palpable vibrations transmitted to chest wall. check front and back
Warm the stethoscope before using!
Sound travels better through solid tissue than air; broncophony, egophony, or whispered pectoriloquy all represent solid or liquid is present.
dlp: Make a diagram of the chest wall, of where to listen
get people to pull arms forward to get scapulae out of the way when listening to back
Tracheal breath sounds are central, harsh, coarse.
Bronchial breath sounds have a higher pitch.
Bronchovesicular are of intermediate pitch.
Vesicular breath sounds have a softer, lower pitch.
Crackles (rales) could be caused by alveoli snapping open, or popping closed. They can be caused by alveolar involvement- pneumonia, fibrosis, or early congestive heart failure - or by problems with the airways - bronchitis or bronchiectasis.
Increases in consolidation may increase the transmission of sound.
Fine crackles are soft high pitched, and very brief.
Rhonchi are coarse sounds occurring during inspiration and expiration. They represent upper airway secretions and can be heard with infection, allergy, COPD, malignancy, or simply with crying.
Wheezes are often audible and palpable vibrations often musical in nature. They are more common on expiration, usually representing obstruction. They may be caused by:
Stridor is a muscial inspiratory wheeze. It suggests obstruction in trachea or larynx and requires immediate attention.
Peristalsis can occasionally be heard in the chest, suggesting diaphragmatic herniation. Pleural friction rub suggests pneumonia, lung abscess, or tuberculosis.
A smaller stethoscope is better to use in infants. Ensure the head is midline.
A crying baby can still provide much information, and in fact inspiration can be well evaluated.
basic respiratory exam video (St George's University Clinical Skills Online)
percussion video (St George's University Clinical Skills Online)
chest expansion video (St George's University Clinical Skills Online)
tracheal deviation video (St George's University Clinical Skills Online)