Fundamentals of the
Chest Physical Exam
RESD 60
Bedside Assessment Skills

Patient Interview

History Taking

Physical Examination

Medical Record
Keeping
Respiratory Recap
 Variables





supporting a therapeutic climate
Caring Demeanor
Competence
Eye Contact
Judicious use of touch
Professional Image
Terms used to describe illness
 Symptom
 Sign
 Finding
 Syndrome
 Disease
Symptom
 Something
felt by an individual as a
departure from normal.
A
subjective abnormality perceived by the
patient.
 Examples:



dyspnea
chest pain
leg swelling
Sign
 An
observable or measurable bodily
manifestation that serves to indicate the
presence of malfunction or disease.
 Examples:



tachypnea
dullness to percussion
pedal edema
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”
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.
Syndrome
A
set of symptoms, signs, and/or findings
that characteristically occur together which
may signify a specific disease process.
 Examples


COPD
pneumonia
Disease
A
particular pathologic condition or
process whose pathophysiology or cause
is known.
 Examples


pneumococcal pneumonia
alpha-1-antitrypsin deficiency
Cardinal signs and symptoms of Cardiopulmonary
Disease
 Dyspnea
 Cough
 Hemoptysis
 Chest
Pain
Cardinal signs and symptoms of
Cardiopulmonary Disease
 Wheezing
 Clubbing
 Stridor
 Edema
 Cyanosis
Dyspnea
 Shortness
of breath
 The
subjective sensation that one’s
breathing is inadequate or insufficient.
 An
uncomfortable awareness of the act of
breathing.
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
Hemoptysis
 The
coughing up of blood from the
respiratory tract below the level of the
larynx.
 This
term is usually reserved for fresh
blood.
Chest Pain
 Any
uncomfortable sensation referable by
the patient to the thoracic area.
 Pleuritic
- worsened by breathing or
coughing.
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.
Stridor
A
harsh, high-pitched sound, usually on
inspiration.
 Associated
with partial laryngeal
obstruction.
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.
Cyanosis
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.
Clubbing of the fingers
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.
Pitting Edema
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.
Physical Examination
A
physical examination is done to detect
the the physical signs of disease.
 The



RCP has 3 considerations:
Diagnostic
Therapeutic
Evaluation
Components of Physical Examination
 Inspection
 Palpation
 Percussion
 Auscultation
Inspection
 View
from the door

Isolation

patient position

Family

equipment
Entering the room
 Introduction
 Patient’s
last name
 Establish
a brief
rapport
Vital Signs

body temperature

heart rate

respiratory rate

blood pressure
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.
Physical Inspection - Head to
Toe
 Head
facial expression
 color
 nose
 mouth
 eyes

Physical Inspection
 Neck

Tracheal position

Jugular venous pressure

Accessory muscle use
Trachea
Tracheal Deviation to the R
Jugular Venous Pressure
JVD
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.
Chest configuration
 Pectus
excavatum - funnel shaped
depression of the lower portion of the
sternum.
 Pectus
carinatum - sternum protrudes
outward.
Sternal Abnormalities
Increased A-P Diameter
Physical examination - spinal
column.
 Scoliosis
- abnormal, lateral curvature of
the spine.
 Kyphosis
- an increased AP curvature of
the spine.
 Kyphoscoliosis
- combination
Kyphosis
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.
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.
Breathing pattern
 Assess
 Look






the patient’s effort to breathe.
for:
retractions
paradoxical respirations
flail chest
chest symmetry
Pursed lips
Tripoding
Pursed Lips
Tripod and Pursed Lips
Physical examination - digits
 The


digits are inspected for:
cyanosis
clubbing
Palpation
 Palpation
is used to evaluate the
symmetry and degree of chest expansion
with breathing.
 Tactile
Fremitus
 Capillary
Refill
 Tracheal
position
To palpate, percuss and auscultate
chest you must know the anatomy.
Posterior View
Palpating for Lung Expansion
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.
Percussion
 Increased
or hyper resonance is a ,
lower pitched sound.
 This
occurs with emphysema or
pneumothorax.
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.
Tactile Fremitus
Auscultation
 Auscultation
is the process of listening to
sounds produced within the body with a
stethoscope.
 Whenever
possible the patient should be
sitting upright.
Stethoscope
Anterior Auscultation
Lateral Auscultation
Posterior Auscultation
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.
Normal Breath Sounds
 Normal
breath sounds are divided into
three different types

Bronchial

Bronchovesicular

Vesicular
Bronchial breath sounds
 Loud
and high-pitched
 equal
inspiratory and expiratory
 heard
over trachea
 also
called tracheal, tracheobronchial or
tubular
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.
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.
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.
Vesicular breath sounds
 Breath
sounds are decreased with the
following:






shallow breathing
hyperinflation
obstructed airways
pleural effusion
pneumothorax
obesity
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.
Adventitious breath sounds
 Abnormal
sounds heard during
auscultation are termed adventitious
breath sounds.
 The
can be continuous, musical sounds or
discontinuous, non-musical.
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.
Continuous/musical
 Low
pitched continuous sounds are
termed rhonchi.
 Timing
is usually expiratory.
 Indicative
of secretions in the lung.
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.
Discontinuous Sounds
 Sounds
described as intermittent,
crackling, bubbling, and of short duration.
 Termed
rales or crackles.
Crackles
 Produced


by two mechanisms;
excessive airway secretions with breathing
and sudden opening of the small airways.
Sudden opening of the small airways.
Crackles
 Crackles
are inspiratory sounds and
associated with restrictive disorders such
as:



atelectasis (late inspiratory)
pneumonia
pulmonary fibrosis
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.
Voice Sounds
 Increase
in vocal resonance is termed
bronchophony.
 An
increase in vocal resonance is heard
with the consolidation that occurs with
pneumonia.
Voice Sounds
A
decrease in vocal resonance occurs
when the lung becomes less dense, as
with hyperinflation.
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.
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.
Neurological Assessment
 LOC


– Level of Consciousness
Glasgow comma scale
PERRLA—pupils equal, round, and
reactive to light and
accommodation
Neurologic Assessment
 Posturing

Decerebrate

Decorticate