PHYSICAL DIAGNOSIS: RESPIRATORY

SYSTEM
Dra. Natividad

Central cyanosis lips, buccal mucosa,

palpebral conjunctiva
11. Altered sensorium

Rule out first if the patient is in:

Respiratory distress
Impending or actual respiratory failure

Examination of Respiratory System

Patient should have his arms folded across their
chest for the scapula to get out of the way
If patient is bedridden: roll the patient from side
to side to examine the back
Dont forget to examine the front
Normal Rate: 12-20
Normal I:E Ratio: 1:2 1:3
Ex: 1:2 in 60 seconds = 20 breaths

Signs of Respiratory Distress/Failure:

1. Irritability/Anxiety
2. Tachypnea
3. Prefer upright position
Facilitate respiration: diaphragm does not
have to contract against the abdominal
contents; aided by gravity
4. Tripod Position
Maximizing length tension relationship of
the accessory muscles of respiration
(Starlings: lengthen the muscle fibers to
contract more efficiently)
5. Speaks in phrases severe form of respiratory
distress
6. Retractions
Supraclavicular
Suprasternal
Intercostals
Subcostal
7. Alar flaring
8. Prominence of accessory muscles including
SCM
9. Abdominal paradox
Asynchronous movement of chest and
abdomen
Work of breathing is so severe, diaphragm
is exhausted
Inspiration: Accessory muscles contracts
chest wall expands increase negative
pressure inside the chest air comes in
diaphragm flaccid and not contracting, sucked
inward
and
upward

relatively
low
intraabdominal pressure abdomen does not
expand
Exhalation: diaphragm does not play a role
anymore accessory muscles squeeze air out
(active process) chest deflates diaphragm
goes back downwards due to increase positive
pressure increase intraabdominal pressure
abdomen inflates
Normal inspiration: chest expands
diaphragm contracts downward increase
negative pressure inside the chest air comes in
when diaphragm contracts and pushes down,
increase intraabdominal pressure abdominal
wall expands
Normal exhalation: diaphragm relaxes air
goes out chest deflates diaphragm goes
back to original position, intraabdominal pressure
decreases abdomen deflates
10. Cyanosis
Type 1 of oxygenation failure

Inspection:
Symmetry of expansion
Chest wall configuration
Palpation:
Tactile fremiti
Percussion:
Resonance, dullness, tympany
Auscultation:
Breath sounds
Vocal Fremiti
Best landmark in the anterior chest?
Sternal Angle of Louis 2nd rib
Landmark in the posterior chest:
Inferior angle of scapula 7th rib or 7th
ICS
INSPECTION
1. Anatomical configuration of the chest
Lateral diameter wider than AP Diameter
Wide AP Diameter, patient is retaining air
hyperinflation
Abnormal:
Pectus carinatum
Pectus excavatum
Scoliosis
No clavicle
Barrel chest wide AP diameter
Midline structures:*
Heart midline if apex beat is in 5 th ICS
MCL
Trachea
2. Symmetry of lung expansion*
*can be a part of inspection or palpation
PALPATION
Palpate for midline structures
Check for lagging hand along the 10th ICS
Palpate for Tactile fremiti ulnar surface of the
hand most sensitive to vibration
PERCUSSION
1. Flat muscle and bone
2. Dull liver or any solid organ
3. Tympany stomach, intestine
4. Resonant air-filled lungs
5. Hyperresonant pathologic, pneumothorax
AUSCULTATION
1. Tracheal - trachea
2. Bronchial manubrium sterni
3. Bronchovesicular 2nd ICS parasternal major lobar bronchi
4. Vesicular rest of lung fields
Extrapulmonary Manifestation of Pulmonary
Problems
1. Clubbing

Severe cardiac or hepatic problem

Lung malignancy
Lung abscess
2. Ptosis, myosis, anhydrosis Horners
syndrome
3. Snoring
4. Obstructive Sleep Apnea excessive
daytime sleepiness

No airflow due to obstruction, brain wakes

the patient up due to lack of O2
Frequent cause of HPN at a very young
age
5. Superior
Vena
Cava
Syndrome

obstruction to the SPV

Due to Malignancy, Prominent veins
6. Unilateral swelling DVT, prone to
pulmonary embolism

Transmission of Sounds
Sounds are transmitted through the large airways
Sound is the consequence of the velocity of airflow and the turbulence
Terminal airways/Small airways velocity is low and surface area is large - no sound transmitted
Principles to Remember:
Anything which increases the distance between the airways and the chest wall will decrease the
transmission of sound
(Ex. Pneumothorax)
If the airways are obstructed, sound will not be transmitted
A solid medium transmit sounds best for as long as airways are patent (solid > liquid > gas), if airways are
obstructed, sound will not be transmitted
(Ex. Mass obstructing the R main bronchus atelectasis of the whole R lung solid still no sound
because airway is not patent)
INSPECTION
Consolidation
(solidified)
Ex. Lower
consolidation lobar
pneumonia (patent
airways)
Pneumothorax
(unilateral)
Emphysema
(bilateral)
Air is contained
inside the alveoli
inflated/
hyperinflated lungs
and alveoli
Overdistended
terminal airways
Hydrothorax
Pleural Effusion
Obstructive
Atelectasis

()
Normal or
Minor lagging
depending on how
big the lung
involvement is
Lagging on
affected side

Lagging
Lagging

PALPATION

PERCUSSIO
N

AUSCULTATI
ON

TRACHEA

Increased TF

Dull

Increased

Midline

Decreased
TF

Hyperreson
ant

Decreased

Contralat
eral

Decreased
TF

Hyperreson
ant

Decreased

Dull

Decreased

Contralat
eral

Dull

Decreased

Ipsilateral

Decreased
TF
Decreased
TF

JLee