1. Fundamentals of the Chest Physical Exam
RESD 60

2. Bedside Assessment Skills
Patient Interview
History Taking
Physical Examination
Medical Record Keeping

3. Respiratory Recap Variables supporting a therapeutic climate
Caring Demeanor
Competence
Eye Contact
Judicious use of touch
Professional Image

4. Terms used to describe illness
Symptom
Sign
Finding
Syndrome
Disease

5. Symptom Something felt by an individual as a departure from normal.
A subjective abnormality perceived by the patient.
Examples:
dyspnea
chest pain
leg swelling

6. Sign
An observable or measurable bodily manifestation that serves to indicate the presence of malfunction or disease.
Examples:
tachypnea
dullness to percussion
pedal edema

7. Sign or symptom
In the investigation of a symptom or sign be quantitative whenever possible.
“8 on a scale of 10”
“2 to 3 minutes”

8. Finding
An observation or manifestation of disease as a result of an investigative procedure.
Typical procedures; blood work, radiology.
Examples:
right lower lobe infiltrate
increase white blood cell count.

9. Syndrome
A set of symptoms, signs, and/or findings that characteristically occur together which may signify a specific disease process.
Examples
COPD
pneumonia

10. Disease
A particular pathologic condition or process whose pathophysiology or cause is known.
Examples
pneumococcal pneumonia
alpha-1-antitrypsin deficiency

11. Cardinal signs and symptoms of Cardiopulmonary Disease
Dyspnea
Cough
Hemoptysis
Chest Pain

12. Cardinal signs and symptoms of Cardiopulmonary Disease
Wheezing
Stridor
Cyanosis
Clubbing
Edema

13. Dyspnea Shortness of breath
The subjective sensation that one’s breathing is inadequate or insufficient.
An uncomfortable awareness of the act of breathing.

14. Cough
A sudden, noisy expulsion of air from the lungs, brought about through a reflex action, for the purpose of clearing the airways.
A normal event that becomes a symptom when it is frequent or bothersome.
Nonproductive or productive

15. Hemoptysis
The coughing up of blood from the respiratory tract below the level of the larynx.
This term is usually reserved for fresh blood.

16. Chest Pain
Any uncomfortable sensation referable by the patient to the thoracic area.
Pleuritic - worsened by breathing or coughing.

17. Wheezing
A high-pitched, musical sound produced when the patient breathes, originating in narrowed airways.
May occupy either a portion or all of the respiratory cycle.

18. Stridor A harsh, high-pitched sound, usually on inspiration.
Associated with partial laryngeal obstruction.

19. Cyanosis
A bluish discoloration of the skin and mucous membranes due to the presence of increased quantities of reduced hemoglobin.
Cyanosis may be peripheral or central.

20. Cyanosis

21. Clubbing
Enlargement of the end of the fingers and toes due to buildup of soft tissue in the nail bed.
Occurs in several chronic lung diseases.

22. Clubbing of the fingers

23. Edema
Presence of large amts of fluid in the intercellular tissue spaces of the body.
Pitting - seen with CHF. Increased fluid due to increased hydrostatic pressure.
Non-pitting - seen with infection due to increased capillary permeability.

24. Pitting Edema

25. Present Illness
The present illness is the clinical problem of primary concern at the moment.
The chief complaint is what caused the patient to seek medical attention.

26. Physical Examination
A physical examination is done to detect the the physical signs of disease.
The RCP has 3 considerations:
Diagnostic
Therapeutic
Evaluation

27. Components of Physical Examination
Inspection
Palpation
Percussion
Auscultation

28. Inspection View from the door Isolation patient position Family
equipment

29. Entering the room Introduction Patient’s last name
Establish a brief rapport

30. Vital Signs body temperature heart rate respiratory rate
blood pressure

31. Sensorium An alert patient is oriented to person, place and time.
An abnormal sensorium suggests that a person may have poor oxygenation.
Can also occur with drugs and disease states.

32. Physical Inspection - Head to Toe
facial expression
color
nose
mouth
eyes

33. Physical Inspection Neck Tracheal position Jugular venous pressure
Accessory muscle use

34. Trachea

36. Tracheal Deviation to the R

37. Jugular Venous Pressure

38. JVD

39. Chest configuration
The normal adult thorax is broader for side to side than front to back.
An increased anteroposterior (AP) diameter is common with emphysema. Barrel chest.

40. Chest configuration
Pectus excavatum - funnel shaped depression of the lower portion of the sternum.
Pectus carinatum - sternum protrudes outward.

41. Sternal Abnormalities

42. Increased A-P Diameter

43. Physical examination - spinal column.
Scoliosis - abnormal, lateral curvature of the spine.
Kyphosis - an increased AP curvature of the spine.
Kyphoscoliosis - combination

44. Kyphosis

45. Physical examination - breathing pattern
Respiratory rate and pattern are always evaluated.
Rapid and shallow breathing is associated with restrictive lung disease.
Prolonged expiratory time is common with obstructive disease.

46. Physical Examination - breathing pattern
Note the timing of the inspiratory and expiratory phase of breathing.
A prolonged expiratory time is common with obstruction of the intrathoracic airways.
Obstruction of the upper airway leads to prolonged inspiratory time.

47. Breathing pattern Assess the patient’s effort to breathe. Look for:
retractions
paradoxical respirations
flail chest
chest symmetry
Pursed lips
Tripoding

48. Pursed Lips

49. Tripod and Pursed Lips

50. Physical examination - digits
The digits are inspected for:
cyanosis
clubbing

51. Palpation
Palpation is used to evaluate the symmetry and degree of chest expansion with breathing.
Tactile Fremitus
Capillary Refill
Tracheal position

52. To palpate, percuss and auscultate chest you must know the anatomy.

53. Posterior View

54. Palpating for Lung Expansion

56. Percussion
Percussion is performed to help evaluate relative amounts of air and solid material in the underlying lung.
Percussion over normal air-filled lung will produce a drum like sound described as normal resonance.

57. Percussion Increased or hyper resonance is a , lower pitched sound.
This occurs with emphysema or pneumothorax.

58. Percussion
Dull or flat describes a note that is softer and higher-pitched than normal.
This sound is heard over areas of pneumonia, atelectasis, lung tumor, or pleural effusion.

60. Tactile Fremitus

61. Auscultation
Auscultation is the process of listening to sounds produced within the body with a stethoscope.
Whenever possible the patient should be sitting upright.

62. Stethoscope

63. Anterior Auscultation

64. Lateral Auscultation

65. Posterior Auscultation

66. Auscultation
Inspiration and expiration should be evaluated for length and adventitious sounds.
Auscultate directly on the skin when possible.
Auscultate anterior, lateral, and posterior chest wall surfaces.

67. Normal Breath Sounds
Normal breath sounds are divided into three different types
Bronchial
Bronchovesicular
Vesicular

68. Bronchial breath sounds
Loud and high-pitched
equal inspiratory and expiratory
heard over trachea
also called tracheal, tracheobronchial or tubular

69. Bronchovesicular breath sounds
Softer and lower pitched than bronchial breath sounds.
Heard on the anterior chest near the mainstem bronchi in the first and second intercostal spaces.
Heard on the posterior chest between the scapulae.

70. Vesicular breath sounds
Soft, low-pitched sounds, heard during auscultation over the lung.
Normal air-filled lung contains millions of alveoli, which act as a sound filter to turbulent flow in the central airways.

71. Vesicular breath sounds
Flow in the peripheral airways is laminar and does not contribute significantly to sound production.
If the vesicular breath sound is softer than expected, it is describes as diminished, decreased, or even absent.

72. Vesicular breath sounds
Breath sounds are decreased with the following:
shallow breathing
hyperinflation
obstructed airways
pleural effusion
pneumothorax
obesity

73. Vesicular breath sounds
Louder than expected vesicular breath sounds are described as harsh.
Consolidation does not filter sound, but allows them to pass through the lung more directly.

74. Adventitious breath sounds
Abnormal sounds heard during auscultation are termed adventitious breath sounds.
The can be continuous, musical sounds or discontinuous, non-musical.

75. Continuous/musical
Wheeze - low pitched sound resulting from narrowing of the airways.
Timing is usually expiratory, but can be inspiratory or both.
“louder” wheezes usually mean moderate obstruction.

76. Continuous/musical Low pitched continuous sounds are termed rhonchi.
Timing is usually expiratory.
Indicative of secretions in the lung.

77. Continuous/musical
A high-pitched continuous sound heard over the upper airway is referred to as stridor.
Stridor is often audible and can be a sign of a life-threatening disorder.

78. Discontinuous Sounds
Sounds described as intermittent, crackling, bubbling, and of short duration.
Termed rales or crackles.

79. Crackles Produced by two mechanisms;
excessive airway secretions with breathing and sudden opening of the small airways.
Sudden opening of the small airways.

80. Crackles
Crackles are inspiratory sounds and associated with restrictive disorders such as:
atelectasis (late inspiratory)
pneumonia
pulmonary fibrosis

81. Voice Sounds
Normally, air-filled lung filters the voice so that it is heard as low-pitched mumble over the chest wall.
When lung tissue becomes dense, vocal resonance increases and the voice is heard more clearly.

82. Voice Sounds Increase in vocal resonance is termed bronchophony.
An increase in vocal resonance is heard with the consolidation that occurs with pneumonia.

83. Voice Sounds
A decrease in vocal resonance occurs when the lung becomes less dense, as with hyperinflation.

84. Voice Sounds
When to voice sound increases in intensity and takes on a nasal or bleating characteristic, it is termed egophony.
Ask the patient to say “e” and the “e” will be heard as “a” over the area of consolidation.

85. Voice Sounds
When consolidation is present, whispered sounds are transmitted more directly.
When whispered sounds are heard with more clarity, they are described as whispered pectoriloquy.

86. Neurological Assessment
LOC – Level of Consciousness
Glasgow comma scale
PERRLA—pupils equal, round, and reactive to light and accommodation

87. Neurologic Assessment
Posturing
Decerebrate
Decorticate