Respiratory History and Physical Exam

 

History

The respiratory history draws on standard components of the history

 

• Identifying Data
• Chief Concern
• History of Presenting Illness
• Past Medical History
• Social History
• Occupational History
• Family History
• Functional Inquiry

 

Chief Concern

 

 

History of Presenting Illness

along with standard HPI questions, ask about:

• cough - time of day, severity, dry and hacking or productive
• sputum - quantity, colour, consistency, time of day
• hemoptysis - source, colour, quantity
• dyspnea - orthopnea, PND, severity
• pain
• wheezing

 

Sputum Evaluation

ask about it, regardless of cough

 

quantity - teaspoons, tablespoons, 1/2 cup

 

• clear, thin sputum - early or mild tracheobroncial inflammation
• yellow/green - results from myeloperoxidase action during cellular breakdown of WBCs during infection
• green - can also be from eosinophils in asthma (non-infectious)
• brownish or grayish - tar and nicotine from cigarettes, especially after quitting
• thick, sticky sputum - from cystic fibrosis
• thin, frothy, pinkish sputum - pulmonary edema
• bad-tasting sputum - anaerobic infection

 

 

Past Medical History

ask especially about prior illnesses, including:

• childhood respiratory illnesses
• asthma
• pneumonia
• TB

 

Social History

ask about travels

environmental history:

• home - animals, humidifiers, heating
• occupation - exposure to chemicals or other agents
• personal - smoking, alcohol, drugs, hobbies

Environmental Factors

CH₂OPD₂ mnemonic (Community, Home, Hobbies, Occupation, Personal habits,
Diet and Drugs)

 

 

Occupational history

• chronological listing of all jobs
• precise job activities
• all materials used in job, with MSDS if possible
• duration and intensity of exposure
• protective measures used, or breached
• ventilation of workplace
• timing relationship of symptoms with shift or vacation
• other workers similarly affected

 

Physical Exam

 

 

• vital signs
• general inspection
• respiratory system inspection
• palpation
• percussion
• auscultation

 

Vital Signs

 

 

Palpation

 

 

 

 

Percussion

 

 

Auscultation

 

Inspection

 

General Inspection

• height, weight, BMI
• development
• nutrition
• edema
• position

 

 

Chest shape

• barrel shaped: asthma, COPD in adults, cystic fibrosis in children
• pectus excavatum
• pectus carinatum

symmetry, integrity

 

 

respiratory distress

• tachypnea
• use of accessory muscles during inspiration
• intercostal indrawing, supraclavicular indrawing
• diaphoresis
• nasal flaring, grunting in infants and children
• pursed lip breathing in adults

 

• audible sounds: snore, stridor, wheeze, ease of speech
• respiratory rhythm - regular, Kussmaul, Biot, Cheyne-stokes
• colour - pigmented, jaundiced, pale, plethoric, cyanosis
• nicotine stains
• clubbing
• skin - lesions, scars
• thoraco-abdominal motion - normal, paradoxical
• bony thorax and AP diameter
• expansion on deep inspiration

position of trachea

 

Percussion

Percussion is one of the most important techniques, establishing whether tissues are fluid-filled, air-filled, or solid.

• pleural effusion will sound flat
• lobar pneumonia will sound dull
• unilateral hyperresonance suggests pneumothorax or COPD

Measure descent of diaphragm, normally 5-6 cm in adults.

 

Dullness is heard over the scapula, liver, heart, and diapragm. It can also be caused by consolidation, fluid, pleural effusion, or pleural thickening.

 

Hyperresonance can be heard with a hyperinflated chest, ie with astma or COPD.

Palpation

 

Areas of tenderness: fractured rib, inflamed pleura. give a squeeze AP and laterally to elicit.

 

chest expansion: place thumbs at level of 10th ribs. placing the hands on the sides is most sensitive.

 

tactile fremitus: palpable vibrations transmitted to chest wall. check front and back

• may be decreased due to obstruction, COPD, pleural effusion, fibrosis, pneumothorax, or tumour
• may be increased due to pneumonia

Auscultation

Warm the stethoscope before using!

Sound travels better through solid tissue than air; broncophony, egophony, or whispered pectoriloquy all represent solid or liquid is present.

 

• listen to bare skin
• breathe through open mouth
• aim for between the ribs

dlp: Make a diagram of the chest wall, of where to listen

get people to pull arms forward to get scapulae out of the way when listening to back

 

 

Normal breath sounds

Tracheal breath sounds are central, harsh, coarse. pause between inspiration and expiration Bronchial breath sounds have a higher pitch. pause between inspiration and expiration can have bronchial breath sounds in areas of consolidation, as can occur during pneumonia, edema, hemmorhage

Bronchovesicular are of intermediate pitch. no pause full Vesicular breath sounds have a softer, lower pitch. no pause between inspiration and expiration ends early during expiration

 

 

Adventitious (abnormal) sounds

Crackles (rales) could be caused by alveoli snapping open, or popping closed. They can be caused by alveolar involvement- pneumonia, fibrosis, or early congestive heart failure - or by problems with the airways - bronchitis or bronchiectasis.   Increases in consolidation may increase the transmission of sound. Fine crackles are soft high pitched, and very brief.   Rhonchi are coarse sounds occurring during inspiration and expiration. They represent upper airway secretions and can be heard with infection, allergy, COPD, malignancy, or simply with crying.

Wheezes are often audible and palpable vibrations often musical in nature. They are more common on expiration, usually representing obstruction. They may be caused by: asthma bronchiolitis CHF COPD pulmonary edema cystic fibrosis foreign body aspiration   Stridor is a muscial inspiratory wheeze. It suggests obstruction in trachea or larynx and requires immediate attention.

Peristalsis can occasionally be heard in the chest, suggesting diaphragmatic herniation. Pleural friction rub suggests pneumonia, lung abscess, or tuberculosis.

 

Pediatrics

A smaller stethoscope is better to use in infants. Ensure the head is midline.

A crying baby can still provide much information, and in fact inspiration can be well evaluated.