Physical Examination of the Respiratory System

1. Initial Survey for respiratory distress

2. Posterior chest (patient sitting, hands folded)
a. Inspection
b. Palpation
c. Percussion
d. Auscultation
3. Anterior chest (patient supine)
a. Inspection
b. Palpation
c. Percussion
d. Auscultation
Note: There is no strict rule if you should examine the posterior chest or anterior chest first. In
Bates, examination of the posterior chest first then proceed to examination of the anterior chest.
In practice, inspection for posterior and anterior chest can be done first.

VERY IMPORTANT - DO NOT FORGET TO:

1. INTRODUCE yourself
2. EXPLAIN what you will be examining
3. ensure CONFIDENTIALITY
4. remember the PATIENT’S NAME
5. DRAPE the patient

Physical Examination Technique Reporting normal findings

INITIAL SURVEY

General survey See the patient’s general The patient is awake, alert,
condition ambulatory, and not in
cardiorespiratory distress

Respiratory rate
Make sure patient is rested and
not talking. Count number of
respirations in 1 minute or in 15
seconds (then multiply by 4).
The patient’s respiratory rate
is _ counts per minute and
not tachypneic or bradypneic.
Normal RR (eupneic): 12-20
(In Bates, normal RR is
14-20)

Check for cyanosis, Check if the patient’s lips look There is no cyanosis or
diaphoresis (and pallor) cyanotic and if the patient is diaphoresis
diaphoretic/sweating, which are
signs of respiratory distress

Check for alar flaring and Inspect the ala of the nose to There is no alar flaring and
use of accessory muscles check for flaring. Inspect the use of accessory muscles.
 neck for accessory muscle use There are no supraclavicular
(SCM scalene muscles) and retractions.
supraclavicular retractions.

Check for positional Check if the patient prefers lean Patient comfortable sitting
preference or position of forward or sit down so that down/in the supine position.
comfort he/she can breathe comfortably
(position of comfort)

Listen for audible sounds Listen if you hear anything while There are no audible sounds
of breathing patient inspires and expires of breathing
even from afar

Can the patient speak in Observe how the patient speaks The patient is able to speak
words, phrases, or in sentences
sentences

POSTERIOR CHEST

INSPECTION

Note shape of the chest Use a measuring tape to get the Patient’s chest is wider than it
by checking the ratio of ratio accurately or estimate it by is deep. (If you were able to
AP diameter to transverse using your hands to check if the measure the AP to transverse
diameter transverse diameter is longer ratio, report it)
than the AP diameter.
The chest is normally
wider than it is deep. The ratio of the anteroposterior
(AP) diameter to the transverse
lateral chest diameter is usually
0.7 to 0.75 up to 0.9 and
increases with aging.

Check for deformities, Pectus excavatum: depressed There are no deformities

visible masses, skin lower sternum such as pectus excavatum or
changes Pectus carinatum: sternum pectus carinatum. There are
displaced anteriorly no visible masses or skin
changes

Check for intercostal Inspect the intercostal spaces There are no intercostal
retraction retractions

Check for chest lag Note if movement of one side of There is no chest lag
the chest is delayed compared
to the other side

PALPATION
Check for tenderness or There are no areas of
crepitus (crackling or tenderness or crepitus
grinding sounds or
sensations)

Test chest expansion There is symmetric/equal

chest expansion

Place thumbs at level of the 10th

ribs, with your fingers loosely
grasping and parallel to the
lateral rib cage. As you position
your hands, slide them medially
just enough to raise a loose fold
of skin between your thumbs
over the spine. Ask the patient to
inhale deeply

Check for tactile fremitus There is symmetric tactile

(palpable vibrations when fremitus
patient is speaking)

Ask the patient to say “tres tres”

or “ninety-nine”
Use ulnar surface of your hand
to feel for tactile fremitus

PERCUSSION
Percuss intercostal On percussion, both sides of
spaces the chest are equally
resonant

Check table at the end

For right-handed people

Pleximeter: left middle finger
Plexor: right middle finger

Check for diaphragmatic Diaphragmatic excursion is _

excursion cm.

Normal: 3 - 5.5 cm

Find the level of the diaphragm

which is dull on percussion. Ask
patient to inspire to full
inspiration and percuss for the
movement of the level of the
diaphragm downward.

AUSCULTATION
Auscultate for breath
sounds
Auscultate for adventitious
Check for auscultatory
vocal fremitus
Auscultate for egophony
Auscultate for whispered
pectoriloquy
Inspection, palpation, and auscultation are more or less the same.
Use diaphragm of your There are clear, symmetric
stethoscope vesicular breath sounds on
Auscultate in ladder pattern bilateral lung fields
Listen for crackles/ rales, There are no adventitious
wheezes, rhonchi breath sounds such as
crackles/rales, wheezes,
rhonchi
Ask the patient to say “tres tres” Auscultatory vocal fremiti are
or “ninety nine” symmetric. There is no
bronchophony.
Normally the sounds transmitted
through the chest wall are
muffled and indistinct.
Louder voice sounds are called
bronchophony.
Ask the patient to say “ee” There is no egophony.
If “ee” sounds like “A” and has a
nasal bleating quality, an E-to-A
change, or egophony, is present.
Ask the patient to whisper “tres The is no whispered
tres” or “ninety-nine” pectoriloquy
Normal: whispered sounds
heard faintly and indistinctly
Whispered pectoriloquy: louder,
clearer whispered sounds
ANTERIOR CHEST
For percussion, structures that can be percussed anteriorly include the liver and the gastric air
bubble.

PERCUSSION