Respiratory Examination

Author: Richard Rathe, MD / rrathe@dean.med.ufl.edu

Copyright: 1996 by the University of Florida
Location: http://medinfo.ufl.edu/year1/bcs/clist/resp.html
Created: January 15, 1996 Modified: July 20, 1999
Equipment Needed
A Stethoscope
A Peak Flow Meter
General Considerations
The patient must be properly undressed and gowned for this examination.
Ideally the patient should be sitting on the end of an exam table.
The examination room must be quiet to perform adequate percussion and
auscultation.
Try to visualize the underlying lobes of the lungs as you examine the patient.
Observe the patient for general signs of respiratory disease (finger clubbing,
cyanosis, air hunger, etc.).
Inspection
1. Observe the rate, rhythm, depth, and effort of breathing. Note whether the
expiratory phase is prolonged.
2. Listen for obvious abnormal sounds with breathing such as wheezes.
3. Observe for retractions and use of accessory muscles (sternomastoids,
abdominals).
4. Observe the chest for asymmetry, deformity, or increased anterior-posterior
(AP) diameter.
5. Confirm that the trachea is near the midline?
Palpation
1. Indentify any areas of tenderness or deformity by palpating the ribs and sternum.
2. Assess expansion and symmetry of the chest by placing your hands on the
patient's back, thumbs together at the midline, and ask them to breath deeply.
3. Check for tactile fremitus.
Percussion
Use the proper technique to elicit percussion "notes."
Posterior Chest
1. Percuss from side to side and top to bottom using the
pattern shown in the illustration. Omit the areas covered by
the scapulae.
2. Compare one side to the other looking for asymmetry.
3. Note the location and quality of the percussion sounds you
hear.
4. Find the level of the diaphragmatic dullness on both sides.
Diaphragmatic Excursion

5. Find the level of the diaphragmatic dullness on both sides.

6. Ask the patient to inspire deeply.
7. The level of dullness (diaphragmatic excursion) should go down 3-5cm
symmetrically.
Anterior Chest
1. Percuss from side to side and top to bottom using the
pattern shown in the illustration.
2. Compare one side to the other looking for asymmetry.
3. Note the location and quality of the percussion sounds you
hear.
Interpretation
Percussion Notes and Their Meaning
Flat or Dull

Pleural Effusion or Lobar Pneumonia

Normal

Healthy Lung or Bronchitis

Hyperresonant Emphysema or Pneumothorax

Auscultation
Use the diaphragm of the stethoscope to auscultate breath sounds.
Posterior Chest
1. Auscultate from side to side and top to bottom using the pattern shown in the
illustration. Omit the areas covered by the scapulae.
2. Compare one side to the other looking for asymmetry.
3. Note the location and quality of the sounds you hear.
Anterior Chest
1. Auscultate from side to side and top to bottom using the pattern shown in the
illustration. [p250]
2. Compare one side to the other looking for asymmetry.
3. Note the location and quality of the sounds you hear.
Interpretation
Breath sounds are produced by turbulent air flow. They are categorized by the size of
the airways that transmit them to the chest wall (and your stethoscope). The general rule
is, the larger the airway, the louder and higher pitched the sound. Vesicular breath
sounds are low pitched and normally heard over most lung fields. Tracheal breath
sounds are heard over the trachea. Bronchovesicular and bronchial sounds are heard in
between. Inspiration is normally longer than expiration (I > E).
Breath sounds are decreased when normal lung is displaced by air (emphysema or
pneumothorax) or fluid (pleural effusion). Breath sounds shift from vesicular to
bronchial when there is is fluid in the lung itself (pneumonia).
Adventitious (Extra) Lung Sounds
Crackles These are high pitched, discontinuous sounds similar to the sound
produced by rubbing your hair between your fingers. (Also known as

Rales)
These are generally high pitched and "musical" in quality. Stridor is an
Wheezes inspiratory wheeze associated with upper airway obstruction (croup).
These often have a "snoring" or "gurgling" quality. Any extra sound that
Rhonchi is not a crackle or a wheeze is probably a rhonchi.
Special Tests
Peak Flow Monitoring
Peak flow meters are inexpensive, hand-held devices used to monitor
pulmonary function in patients with asthma. The peak flow roughly
correlates with the FEV1.
1. Ask the patient to take a deep breath.
2. Then ask them to exhale as fast as they can through the peak flow
meter.
3. Repeat the measurement 3 times and report the average.
Voice Transmission Tests
These tests are only used in special situations. This part of the physical exam has largely
been replaced by the chest x-ray. All these tests become abnormal when the lungs
become filled with fluid (referred to as consolidation).
Tactile Fremitus
Whispered Pectoriloquy
1. Ask the patient to whisper "ninety-nine" several times.
2. Auscultate several symmetrical areas over each lung.
3. You should hea
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