1S_1_PHYSICAL DIAGNOSIS OF RESPIRATORY SYSTEM (PART 2)

PE: INSPECTION:

1. G_____ I_____ N

2. THORACIC C_____ UR

3. S_____ Y

4. R_____ S

5. SIGNS OF U_____ A_____ Y OBSTRUCTION

6. SIGNS OF S_____ C OBSTRUCTION

7. SIGNS OF I_____ C OBSTRUCTION

8. P_____ L SIGNS

1. GENERAL IMPRESSION

2. THORACIC CONTOUR

3. SYMMETRY

4. RETRACTIONS

5. SIGNS OF UPPER AIRWAY OBSTRUCTION

6. SIGNS OF SUPRAGLOTTIC OBSTRUCTION

7. SIGNS OF INFRAGLOTTIC OBSTRUCTION

8. PERIPHERAL SIGNS

PE: INSPECTION: GENERAL IMPRESSION:

1. P____N

2. C____R

3. M____L ST____S

4. ABILITY TO S____K

5. R____Y EFFORT

1. POSITION

2. COLOR

3. MENTAL STATUS

4. ABILITY TO SPEAK

5. RESPIRATORY EFFORT

PE:INSPECTION: GENERAL IMPRESSION:

Sign of cardiorespiratory distress due to better exchange of CO2 and Oxygen

TRIPOD POSITION

PE: INSPECTION: THORACIC CONTOUR:

1. B___ CHEST

2. PECTUS E___M

3. PECTUS C___M

4. K___S

5. S___S

6. K___IS

1. BARREL CHEST

2. PECTUS EXCAVATUM

3. PECTUS CARINATUM

4. KYPHOSIS

5. SCOLIOSIS

6. KYPHOSCOLIOSIS

PE: INSPECTION: THORACIC CONTOUR:

BARREL CHEST:

1. Sign of air t____

2. Chronic a____a

3. E____a

4. C____ f____s

BARREL CHEST:

1. Sign of air trapping

2. Chronic asthma

3. Emphysema

4. Cystic fibrosis

PE: INSPECTION: THORACIC CONTOUR:

Compression of the heart & great vessels may cause murmurs

Pectus Excavatum (Funnel or Sunken Chest)

PE: INSPECTION: THORACIC CONTOUR:

Doesn’t really impact negatively on the heart or the lungs UNLESS associated with some inborn metabolic derangement or any bony abnormalities

Pectus Carinatum (Pigeon Chest)

PE: INSPECTION: THORACIC CONTOUR:

Definitely compromises heart & lungs; Compresses and limits the airways

KYPHOSIS

PE: INSPECTION: THORACIC CONTOUR:

More compressive than kyphosis; One must be fast in detecting early on s/sx, in other to prevent complications

SCOLIOSIS

PE: INSPECTION: THORACIC CONTOUR:

Kyphosis + Scoliosis

KYPHOSCOLIOSIS

PE: INSPECTION: SYMMETRY:

What is greater: AP or transverse diameter

transverse diameter

PE: INSPECTION: SYMMETRY:

Transverse diameter values

Should NOT be > 0.70 - 0.75

PE: INSPECTION: SYMMETRY:

AP diameter increases c ___ (Up to ___)

AP diameter increases c age (Up to 0.9)

PE: INSPECTION: SYMMETRY:

Unequal expansion and respiratory compromise 

Chest symmetry

PE: INSPECTION: SYMMETRY: CHEST ASYMMETRY

caused by:

1. C____d l____ on the i____al side

2. Limitation of e____n

3. Check the s____er, b____st, and hi____

1. Collapsed lung on the ipsilateral side 

2. Limitation of expansion 

3. Check the shoulder, breast, and hip 

PE: INSPECTION: SYMMETRY: CHEST ASYMMETRY

Etiology:

1. E____l air

2. F____

3. M____

1. Extrapleural air

2. Fluid

3. Mass

PE: INSPECTION: SYMMETRY: CHEST ASYMMETRY

Etiology: pneumothorax, lagging, air that escaped the lungs & is in the pleural cavity

EXPTRAPLEURAL AIR

PE: INSPECTION: SYMMETRY: CHEST ASYMMETRY

Etiology: pleural effusion, one lung has more fluid so it limits expansion

FLUID

PE: INSPECTION: SYMMETRY: CHEST ASYMMETRY

Etiology: lung or thoracic tumor, any tumor that could compress the lungs

MASS

PE: INSPECTION: Suggest an obstruction to inspiration at any point in the respiratory tract

RETRACTION

PE: INSPECTION: RETRACTION:

I_____l pressure becomes increasingly negative degree and level of retraction depend on the extent and level of obstruction

Intrapleural

PE: INSPECTION: UPPER AIRWAY OBSTRUCTION:

SIGNS:

1. I____y S____

2. H____e cough or cry or b____ cough 

3. A____ flaring

4. Retraction at the s____ notch

5. C____

6. S____ (bat-like sound)

1. Inspiratory Stridor

2. Hoarse cough or cry or barking cough

3. Alar flaring

4. Retraction at the suprasternal notch

5. Cyanosis

6. Stridor (bat-like sound)

SABCS

PE: INSPECTION: UPPER AIRWAY OBSTRUCTION:

SIGNS: Like a whistling or squeaky sound when sucking air through a tiny straw during inhalation

Inspiratory Stridor

PE: INSPECTION: UPPER AIRWAY OBSTRUCTION:

SIGNS: Voice sounds rough or hoarse, cough sounds like a dog barking.

Hoarse cough or cry or barking cough

PE: INSPECTION: UPPER AIRWAY OBSTRUCTION:

SIGNS: Sign of air hunger

Alar flaring

PE: INSPECTION: UPPER AIRWAY OBSTRUCTION:

SIGNS: Could tell level of obstruction

Retraction at the suprasternal notch

PE: INSPECTION: UPPER AIRWAY OBSTRUCTION:

SIGNS: signs of low level of oxygen

CYANOSIS

PE: INSPECTION: something is blocking the area above the vocal cords

SUPRAGLOTTIC OBSTRUCTION

PE: INSPECTION: Something is blocking the airway below the vocal cords (trachea or just below the larynx)

INFRAGLOTTIC OBSTRUCTION

PE: INSPECTION: SUPRAGLOTTIC OR INFRAGLOTTIC OBSTRUCTION:

Stridor tends to be quieter

SUPRAGLOTTIC

PE: INSPECTION: SUPRAGLOTTIC OR INFRAGLOTTIC OBSTRUCTION:

Muffling voice (hot potato in mouth)

SUPRAGLOTTIC

PE: INSPECTION: SUPRAGLOTTIC OR INFRAGLOTTIC OBSTRUCTION:

Dysphagia

SUPRAGLOTTIC

PE: INSPECTION: SUPRAGLOTTIC OR INFRAGLOTTIC OBSTRUCTION:

No cough

SUPRAGLOTTIC

• Because you’re not irritating the most irritating part of the airways

PE: INSPECTION: SUPRAGLOTTIC OR INFRAGLOTTIC OBSTRUCTION:

Awkward position of head and neck to preserve the airway

SUPRAGLOTTIC

• Looking for that position to establish a good airway (air can come in better)

PE: INSPECTION: SUPRAGLOTTIC OR INFRAGLOTTIC OBSTRUCTION:

Stridor tends to be louder, rasping

INFRAGLOTTIC

PE: INSPECTION: SUPRAGLOTTIC OR INFRAGLOTTIC OBSTRUCTION:

Hoarse voice

INFRAGLOTTIC

PE: INSPECTION: SUPRAGLOTTIC OR INFRAGLOTTIC OBSTRUCTION:

Swallowing not affected

INFRAGLOTTIC

PE: INSPECTION: SUPRAGLOTTIC OR INFRAGLOTTIC OBSTRUCTION:

Cough is harsh, barking

INFRAGLOTTIC

PE: INSPECTION: SUPRAGLOTTIC OR INFRAGLOTTIC OBSTRUCTION:

Head positioning is not a factor

INFRAGLOTTIC

• Because no matter the position of the head, pt will still have difficulty breathing since the obstruction is infraglottic, which is more difficult to attend to

PE: INSPECTION: PERIPHERAL SIGNS:

1. C_____s

2. P_____g

3. C_____g

4. A_____ flaring

5. Suggest c_____c or p_____ry difficulty

1. Cyanosis

2. Pursing

3. Clubbing

4. Alar flaring

5. Suggest cardiac or pulmonary difficulty

PE: INSPECTION: PERIPHERAL SIGNS:

Cyanosis: (2)

1. l__

2. n__

1. lips

2. nails

PE: INSPECTION: PERIPHERAL SIGNS:

Cyanosis vs Pale: lack of blood flow

Pale

PE: INSPECTION: PERIPHERAL SIGNS:

Cyanosis vs Pale: Normal blood flow but high CO2 (hypoxemia or hypercarbia/hypercapnia) 

Cyanosis

PE: INSPECTION: PERIPHERAL SIGNS:

Pursing: what body part

lips — pursed lip breathing

PE: INSPECTION: PERIPHERAL SIGNS:

Almost always indicates chronic hypoxemia

Clubbing: finger nails

PE: INSPECTION: PERIPHERAL SIGNS:

air hunger, esp. alveolar involvement 

Alar flaring

PE: AUSCULTATION:

Inch by inch; Provides important conditions of the lungs and pleura 

AUSCULTATION 

PE: AUSCULTATION: Breath sounds:

1. I___

2. P___h

3. Q___y

4. D___n

1. Intensity

2. Pitch

3. Quality

4. Duration

PE: AUSCULTATION: Breath sounds:

Bulk of the lungs is often felt p__ and l__

posteriorly and laterally (tissues anteriorly are thin)

PE: AUSCULTATION: Breath sounds:

Breath sounds are usually louder in the u___ a___r lung fields. 

upper anterior lung fields.

PE: AUSCULTATION: NORMAL BREATH SOUNDS:

1. V_____R

2. B_____R

3. B_____L/T_____L (T_____)

1. VESICULAR

2. BRONCHOVESICULAR

3. BRONCHIAL/TRACHEAL (TUBULAR)

PE: AUSCULTATION: NORMAL BREATH SOUNDS:

heard over most of the lungs 

VESICULAR

PE: AUSCULTATION: NORMAL BREATH SOUNDS:

low pitch 

VESICULAR

PE: AUSCULTATION: NORMAL BREATH SOUNDS:

soft and short expiration 

VESICULAR

PE: AUSCULTATION: NORMAL BREATH SOUNDS:

more prominent in thin individuals or children 

VESICULAR

PE: AUSCULTATION: NORMAL BREATH SOUNDS:

diminished in the overweight or muscular individuals 

VESICULAR

PE: AUSCULTATION: NORMAL BREATH SOUNDS:

heard over the main bronchus area and over upper right posterior lung field 

BRONCHOVESICULAR

PE: AUSCULTATION: NORMAL BREATH SOUNDS:

medium pitch 

BRONCHOVESICULAR

PE: AUSCULTATION: NORMAL BREATH SOUNDS:

expiration equals inspiration 

BRONCHOVESICULAR

PE: AUSCULTATION: NORMAL BREATH SOUNDS:

heard only over trachea 

BRONCHIAL/TRACHEAL (TUBULAR)

PE: AUSCULTATION: NORMAL BREATH SOUNDS:

high pitch 

BRONCHIAL/TRACHEAL (TUBULAR)

PE: AUSCULTATION: NORMAL BREATH SOUNDS:

loud and long expirations, sometimes a bit longer than inspirations 

BRONCHIAL/TRACHEAL (TUBULAR)

PE: AUSCULTATION: ADVENTITIOUS/ABNORMAL BREATH SOUNDS:

1. F___ CRACKLES

2. M___ CRACKLES

3. C___ CRACKLES

4. R___

5. W___

6. P___L F___N RUB

1. FINE CRACKLES

2. MEDIUM CRACKLES

3. COARSE CRACKLES

4. RHONCHI

5. WHEEZE

6. PLEURAL FRICTION RUB

PE: AUSCULTATION: ADVENTITIOUS/ABNORMAL BREATH SOUNDS:

high-pitched, dicrete, discontinuous crackling at the end of inspiration 

FINE CRACKLES

PE: AUSCULTATION: ADVENTITIOUS/ABNORMAL BREATH SOUNDS:

not cleared by a cough 

FINE CRACKLES

PE: AUSCULTATION: ADVENTITIOUS/ABNORMAL BREATH SOUNDS:

AKA rales

FINE CRACKLES

PE: AUSCULTATION: ADVENTITIOUS/ABNORMAL BREATH SOUNDS:

FINE CRACKLES/RALES: Early inspiratory & expiratory crackles can suggest?

chronic bronchitis

PE: AUSCULTATION: ADVENTITIOUS/ABNORMAL BREATH SOUNDS:

FINE CRACKLES/RALES: Late inspiratory crackles can suggest:

1. p___

2. c___ h___ fa___

3. a___

1. pneumonia

2. congestive heart failure

3. atelectasis

PE: AUSCULTATION: ADVENTITIOUS/ABNORMAL BREATH SOUNDS:

loud, bubbly noise 

COARSE CRACKLES

PE: AUSCULTATION: ADVENTITIOUS/ABNORMAL BREATH SOUNDS:

COARSE CRACKLES heard during?

heard during inspiration

PE: AUSCULTATION: ADVENTITIOUS/ABNORMAL BREATH SOUNDS:

not cleared by a cough 

COARSE CRACKLES

PE: AUSCULTATION: ADVENTITIOUS/ABNORMAL BREATH SOUNDS:

Longer duration than fine crackles

COARSE CRACKLES

PE: AUSCULTATION: ADVENTITIOUS/ABNORMAL BREATH SOUNDS:

lower, moist sound during the midstage of inspiration 

MEDIUM CRACKLES

PE: AUSCULTATION: ADVENTITIOUS/ABNORMAL BREATH SOUNDS:

not cleared by a cough

MEDIUM CRACKLES

PE: AUSCULTATION: ADVENTITIOUS/ABNORMAL BREATH SOUNDS:

sibilant wheeze 

WHEEZE

PE: AUSCULTATION: ADVENTITIOUS/ABNORMAL BREATH SOUNDS:

musical noise like a squeak 

WHEEZE

PE: AUSCULTATION: ADVENTITIOUS/ABNORMAL BREATH SOUNDS:

most often heard continuously during inspiration or expiration 

WHEEZE

PE: AUSCULTATION: ADVENTITIOUS/ABNORMAL BREATH SOUNDS:

WHEEZE usually heard/louder in?

usually louder during expiration

PE: AUSCULTATION: ADVENTITIOUS/ABNORMAL BREATH SOUNDS:

sonorous wheeze, snore-like 

RHONCHI

PE: AUSCULTATION: ADVENTITIOUS/ABNORMAL BREATH SOUNDS:

loud, low, coarse sounds most often heard continuously during inspiration or expiration 

RHONCHI

PE: AUSCULTATION: ADVENTITIOUS/ABNORMAL BREATH SOUNDS:

coughing may clear the sound (mucus accumulation in trachea or large bronchi) 

RHONCHI

PE: AUSCULTATION: ADVENTITIOUS/ABNORMAL BREATH SOUNDS:

dry, rubbing, or grating usually caused by inflammation of pleural surfaces 

PLEURAL FRICTION RUB

PE: AUSCULTATION: ADVENTITIOUS/ABNORMAL BREATH SOUNDS:

PLEURAL FRICTION RUB heard during?

heard during inspiration or expiration

PE: AUSCULTATION: ADVENTITIOUS/ABNORMAL BREATH SOUNDS:

loudest over lower lateral anterior surface

PLEURAL FRICTION RUB

PE: PALPATION:

1. T____ E____N

2. C____S

3. P____L F____N R____

4. T____ F____S

5. T____A

1. THORACIC EXPANSION

2. CREPITUS

3. PLEURAL FRICTION RUB

4. TACTILE FREMITUS

5. TRACHEA

PE: PALPATION: THORACIC EXPANSION:

1. Place a t____ on the midline and ask the pt to take a deep breath

2. Checking for s____y

3. Checking for lung e____n

4. Hands placed at l____ border of rib cage usually ____th/____th rib

5. Ask the patient to inhale and observe the ____ of the two thumbs

1. Place a thumb on the midline and ask the pt to take a deep breath

2. Checking for symmetry

3. Checking for lung expansion

4. Hands placed at lower border of rib cage usually 10th/11th rib

5. Ask the patient to inhale and observe the separation of the two thumbs

PE: PALPATION: THORACIC EXPANSION:

Abnormal response

lagging on one side (chest lagging) 

PE: PALPATION: THORACIC EXPANSION:

chest lagging may be an indication of:

1. A____

2. T____r

3. F____ inside thoracic cage

4. Anything getting in the way of lung e____

1. Atelectasis

2. Tumor

3. Fluid inside thoracic cage 

4. Anything getting in the way of lung expanding 

PE: PALPATION: A crackly, or crinkly sensation, a gentle and bubbly feeling when skin is pressed 

CREPITUS

PE: PALPATION: Indicates air in the subcutaneous tissue from a rupture somewhere in the respiratory system by infection from a gas-producing organism 

CREPITUS

PE: PALPATION: May be localized or generalized 

CREPITUS

PE: PALPATION: Palpable, coarse, grating vibration 

PLEURAL FRICTION RUB

PE: PALPATION: like friction

PLEURAL FRICTION RUB

PE: PALPATION:

PLEURAL FRICTION RUB usually on?

usually on inspiration

• but both heard in inspiration & expiration

PE: PALPATION: feel of leather rubbing on leather 

PLEURAL FRICTION RUB

PE: PALPATION: Palpable vibration of the chest wall that results from speech or other verbalizations 

TACTILE FREMITUS

PE: PALPATION: TACTILE FREMITUS:

best felt p____y at the ____nd ICS at the level of the b____ of b____

parasternally at the 2nd ICS at the level of the bifurcation of bronchi

PE: PALPATION: TACTILE FREMITUS:

words to say (3)

1. 99

2. tres-tres

3. mickey mouse

PE: PALPATION: TACTILE FREMITUS:

INCREASE OR DECREASED: Excess air in the lungs

DECREASED

PE: PALPATION: TACTILE FREMITUS:

INCREASE OR DECREASED: Emphysema

DECREASED