Single Organ System Exam

Respiratory

Created by The Lung Doctor

 Single Organ System Exam
Respiratory
Comprehensive Level
Perform and document ALL Perform and document at least 1
elements in the following element in each of the following
organ systems
Musculoskeletal
 Constitutional
 ENT Inspection Extremities
 Neck Skin
 Respiratory Neurologic
 Cardiovascular
 Gastrointestinal
 Lymphatic

Created by The Lung Doctor

 Single Organ System Exam
Respiratory
Constitutional
Document at least 3 vital signs as follows
 Blood Pressure
– Sitting OR Standing
 Blood Pressure
– Lying
 Pulse
– Rate AND Regularity
 Temperature
 Height
 Weight
Note: May be measured and recorded by ancillary staff

Created by The Lung Doctor

 Single Organ System Exam
Respiratory
Ears, Nose, Mouth, Throat
Inspection of nasal mucosa, septum,
turbinates
Inspection of teeth and gums
Examination of oropharynx
 Oral mucosa, hard and soft palates, tongue,
tonsils, and posterior pharynx

Created by The Lung Doctor

 Single Organ System Exam
Respiratory
Neck
Examination of neck
 Masses, overall appearance, symmetry, tracheal
position, crepitus
Examination of thyroid
 Enlargement, tenderness, mass
Examination of jugular veins
 Distension, a, v or cannon a waves

Created by The Lung Doctor

 Single Organ System Exam
Respiratory
Respiratory
Inspection of chest with notation of symmetry and
expansion
Assessment of respiratory effort
 Intercostal retractions, accessory muscle use, and
diaphragmatic movement
Percussion of chest
 Dullness, flatness, hyperresonance
Palpation of chest
 Tactile fremitus
Auscultation of lungs
 Breath sounds, adventitious sounds, rubs

Created by The Lung Doctor

 Single Organ System Exam
Respiratory
Cardiovascular
Auscultation of heart sounds, abnormal
sounds and murmurs
Examination of peripheral vascular system by
observation and palpation
 Swelling and varicosities
 Pulses, temperature, edema, tenderness

Created by The Lung Doctor

 Single Organ System Exam
Respiratory
Gastrointestinal (Abdominal)
Examination of abdomen with notation of
presence or absence of masses or
tenderness
Examination of liver and spleen

Created by The Lung Doctor

 Single Organ System Exam
Respiratory
Lymphatic
Palpation of lymph nodes
 Neck
 Groin
 Axilla
 Other location

Note: Exam of at least 2 locations must be documented

Created by The Lung Doctor

 Single Organ System Exam
Respiratory
Perform and document at least 1 of the following
Musculoskeletal
Assessment of muscle strength and tone with
notation of any atrophy and abnormal
movements
 Flaccid, cogwheel, spastic
Examination of gait and station

Created by The Lung Doctor

 Single Organ System Exam
Respiratory
Perform and document at least 1 of the following
Extremities
Inspection and palpation of digits and nails
 Clubbing, cyanosis, inflammation, petechiae,
ischemia, infections, nodes

Created by The Lung Doctor

 Single Organ System Exam
Respiratory
Perform and document at least 1 of the following
Skin
Inspection and/or palpation of skin and
subcutaneous tissue
 Rashes, lesions, ulcers

Created by The Lung Doctor

 Single Organ System Exam
Respiratory
Perform and document at least 1 of the following
Neurological/Psychiatric
Brief assessment of mental status
 Include orientation to person, time and place
 Include mood and affect
– Anxiety, depression, agitation

Created by The Lung Doctor