Skill Laboratory Module

BLOCK : Respiratory system

TOPIC : History taking & Physical examination in adults & pediatric respiratory patient

I. GENERAL OBJECTIVE
After completing skill practice, the student will be able to perform respiratory physical
examination.

II. SPECIFIC OBJECTIVE

At the end of skill practice, the student will be able to perform the procedure of respiratory
physical examination systematically including:
 Systematic physical examination of respiratory system by performing inspection,
palpation, percussion and auscultation

III. SYLLABUS DESCRIPTION

3.1 Sub Module Objective

After finishing skill practice of clinical examination, the student will be able to perform
physical examination of respiratory disorders

3.2 Expected competencies

Student will be able to demonstrate the procedure of physical examination respiratory
disorders

3.3. Method
a. Presentation
b. Demonstration
c. Coaching
d. Self practice : role-play

3.4 Laboratory facilities

a. Skills laboratory: table, chairs, and examination couch
b. Patient : model
d. Student learning guide
e. Trainer’s guide
f. References

3.5 Venue
Skills laboratory
3.6 Evaluation
a) Point nodal evaluation
b) OSCE

3.7. Sub Model Objective

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 After finishing skill practice of clinical examination, the student will be able to
perform respiratory system physical examination.

3.8. Expected Competencies

1. The learner will be able to demonstrate the history taking in pediatric and adult
respiratory patients including conclusion the diagnosis
2. The learner will be able to demonstrate the procedure of physical examination
of :
 Locating Cervical lymph node
 Tracheal position
 Locating chest abnormalities vertically and circumferentially
 Shape and movement of the chest
 Tactile fremitus
 Chest Percussion
 Normal breath sounds
 Presence and absent of adventitious sounds
 Presence and absent of transmitted voice sounds (bronchophony,
egophony and whispered pectoriloquy)

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IV. LEARNING GUIDE FOR HISTORY TAKING OF ADULT RESPIRATORY
PATIENT

Performance Scale
No Steps/Tasks
0 1 2
1. Say Basmalah
2. Greet the patient and introduce your self
Preparation
3. Should be taken in an environment with comfort and privacy for patient
4. Record patient identity (name, address, marital status)
5. Explain the procedure and its goals to the patient. Ask for informed
consent
Structure of history taking (auto/ allo-anamnesis)
6. Chief complaint : Difficulty of breathing
 The onset and duration
 Is it spontaneously or after some specific event?
 Enquires if this is a first episode or a recurrence?
 Progresivity (Is it slowly progressive ?, sudden onset of dyspnea ?
episodic and recurrent ? )
 Symptoms should be defined by their qualitative and quantitative
characteristics (aggravating and alleviating factors associated
manifestazations)
1. Factors that aggravate (is the dyspneu worsen with position
(supine, lying down to right/left), is the dyspneu worsen with exertion
or rest, is the dyspneu worsen with allergens, irritants, respiratory
infections, emotion)
2. Factors that relieve (is the dyspneu relieve with position (rest,
sitting up), is the dyspneu relieve with expectorant medications, is the
dyspneu relieve with separation from aggravating factors)
 The relation between respiratory symptom and daily activities, diurnal
variation, food intake
 To know whether other family members also affected
7. Associated signs and symptoms of respiratory disease
 Fever
 Cough (productive or non-productive, hemaptoe)
 Noisy breathing
- Wheezing
- Stridor
 Dyspnea on exertion or rest
 Orthopnea
 Paroxysmal nocturnal dyspnea
 Pleuritic pain
 Edema
 Cyanosis
 Recurrent respiratory infections

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  Palpitation
 Chest pain (if any ask the location : retrosternal, precordial, radiating)
 History of chocking
 History of smoking cigarettes
 Allergies
 Medications (drugs that affect the symptoms)
8. Treatment history (types, doses, preparations, responses)
9. Say Hamdalah
10. Conclusion with Differential Diagnosis

V. LEARNING GUIDE FOR HISTORY TAKING OF PEDIATRIC RESPIRATORY

PATIENT

Performance Scale
No Steps/Tasks
0 1 2
1. Say Basmalah
2. Greet the patient and introduce your self
Preparation
3. Should be taken in an environment with comfort and privacy for patient
4. Record patient identity (name, address, body weight)  ortunya juga,
alamt pekerjaan
5. Explain the procedure and its goals to the patient. Ask for informed
consent  menanyakan beberapa hal mengenai keluhan, diharapkan
sesuai dan jujur, agar gambaran nya sakit apa? Bersedia atau tidak?
Structure of history taking (auto/ allo-anamnesis)
6. Chief complaint : Difficulty of breathing
 The onset and duration  dari kapan?
 Is it spontaneously or after some specific event?  pagi siang atau
malam mulai nya?
 Enquires if this is a first episode or a recurrence?  tibatiba lagi tidur
atau abis main?
 Progresivity  baru sekarang atau sebelum nya udah pernah? makin
sesak/tidak
 Symptoms should be defined by their qualitative and quantitative
characteristics (aggravating or alleviating and relieving factors
associated manifestations)  kalo lagi tiduran/ digendong membaik
atau tidak? Pas lagi apa ga sesek?
 The relation between respiratory symptom and daily activities, diurnal
variation, food intake  dipengaruhi oleh main/ makanan?
 To know whether other family members also affected  ada yang
punya gejala yang sama ga di keluarga?
7. Common signs and symptoms of respiratory disease
 Cough  dahak, warna, bau, darah?
 Fever  berapa hari? Hangat/tinggi?

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  Noisy breathing
- Wheezing / mengi
- Stridor / ngorok, padahal ga tidur
 Dyspnea on exertion or rest  dipengaruhi oleh istirahat hilang/
aktiftas sesak?
 Cyanosis  kebiruan di ujung kuku/ sekitar mulut?
 History of chocking  makan lancar atau tidak? Suka tersedak? Asi?
Susu formula bisa minum?
 Allergies  makanan, cuaca, debu, riwayat di keluarga? Asma di
keluarga?
 Medications (drugs that affect the symptoms)  dikasih obat tertentu
jadi sesak?
8. Treatment history (types, doses, preparations, responses)  pas berobat
di kasih obat apa aja? Sirup/tablet? Berapa kali sehari? Berkurang atau
tidak gejala nya?
10. The Birth history should be reviewed including prenatal, natal and
neonatal  lahir dimana? Ingat bb? Lahir cukup bulan? Normal/tidak?
Langusng nagis/tdk?, pernah dirawat di rs?
11. Feeding history (the amount, type and schedule food intake)  yang diberi
seharihari, makan nasi? Porsinya? Habis/tdk?
12. Growth and development  tinggi sama ga sama yang lain? Udah bisa apa
anak nya, jalan lari?
13. A detailed report of prior tests and immunizations should be obtained 
terakhir imunisasi? Lengkap ga?
14. Say Hamdalah
15. Conclusion with Differential Diagnosis (radang paru,
Perlu pemeriksaan fisik

VI. LEARNING GUIDE FOR PHYSICAL EXAMINATION OF ADULT

RESPIRATORY PATIENT

No Steps/ Task 1 2 3 4 5

A. CLIENT ASSESSMENT
1. Greet client respectfully and with kindness
2. The patient should be given adequate explanation about physical
examination and the goal or expected result of physical examination
3. Identifying patient’s data (make sure the data match with medical
record)

B PHYSICAL EXAMINATION
I PREPARATION
1 Tell the patient what is going to be done
2 Help the patient on to the examination table

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3 Wash hands thoroughly with soap and water and dry with a clean dry
towel or air drier
4 The examiner should stand at the patient’s right side

II EXAMINATION TECHNIQUE
A General Physical Examination (described elsewhere)

B Locating Cervical Lymph Nodes

1. Make the patient comfortable and relax
2. Flexed the neck slightly forward and if needed slightly toward the
examination
3. Palpate using the pads of your index and middle fingers
4. Move the skin over the underling tissue in each area
5. Describe location, quantity, size (diameter), consistency, movability,
presence specific formation (package).

Findings :
1 Preauricular – in front of the ear
2 Posterior auricular – superficial to mastoid process
3 Occipital – at the base of the skull posteriorly
4 Tonsilar – at the angle of mandible
5 Submandibular – midway between the angle and the tip of the
mandible. These nodes are usually smaller and smoother than
lobulated submandibular gland against which they lie
6 Submental – in the midline a few cm behind the tip of
mandible
7 Superficial cervical – superficial to sternomastoid
8 Posterior cervical – along the anterior edge of trapezius
9 Deep cervical chain – deep to the sternomastoid and often
inaccessible to examination. Hook your thumb and fingers
around either side of the sternomastoid muscle to find them
10 Supraclavicular – deep in the angle formed by the clavicle and
the sternomastoid
C TRACHEA
1. Inspect trachea for any deviation from its midline position.
2. Place the finger along one side of the trachea and note
the space between trachea and the sternomastoid.
3. Compare it with the other side. Normally the space
should be symmetrical.

D Locating Chest abnormalities To locate vertically Anterior chest

1. Identify the suprasternal notch
2. Move your down about 5 cm
3. Find the horizontal bony ridge that join the manubrium to the
body of sternum.
4. Move your finger laterally and find the adjacent 2 nd rib and

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 costal cartilage
5. From here you can walk down the interspaces.
6. The first intercostals space below the 2 nd rib is the second
intercostals space.
7. Identify mid sternal line, midclacivular line and anterior,
posterior and mid axillary line

To locate findings around the circumference of the chest

1. midsternal and vertebral are lines drops vertically mid sternal
and midvertebral
2. identify both end of the clavicle and the midclavicular line drops
vertically from the mid point of clavicle.
3. Anterior and posterior axillary lines drop vertically from the
anterior and posterior axillary folds
4. The midaxillary line drops from the apex of the axilla

Posterior chest :
1. Flexed the patients neck forward
2. Find the most prominent process
3. The most prominent is the C7
4. When two process appear equally prominent they are C7 and T1
5. Then you can felt and counted the process below them
6. You can also estimating location from location of inferior angle of
scapula is usually leis at the level of the 7th rib of interspace.

TECHNIQUES OF CHEST EXAMINATION

Examine the anterior chest
Inspection :
1. Place the patient in supine position
2. Your position is in the midline position in front of the patient foot
3. Inspect the shape of the chest and the way in which it moves
4. Findings : deformities or asymmetry, abnormal retraction of
interspace during inspiration, impairment of respiratory movement
on one or both side or a unilateral lag (delay) in the movement.

Palpation
Test respiratory expansion
1. place your thumb about at the level of and parallel to the 10 th ribs,
your hands grasping the lateral rib cage.
2. Slide your hand medially a bit in order to raise loose skin folds
between your thumb and the spine.
3. ask the patient to inhale deeply
4. Watch the divergence of your thumbs during inspiration and feel for
the range and symmetry of respiratory as the thorax expands and
feel for the extent and symmetry of respiratory movement.

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Tactile fremitus
a. use either the ball (the bony part of the palm at the base of the
fingers) or the ulnar surface of your hand and place it in both side of
the chest symmetrically
b. ask the patients to repeat the words “ninety nine” or “one – one –
one”
c. repeat this examinations in other areas of the chest symmetrically

Percussion :
1. hyperextend the middle finger of your left hand (the pleximeter
finger)
2. press its distal interphalangeal joint firmly on the surface to be
percussed.
3. AVOID contact by any other part of the hand
4. Position your right forearm quite close to the surface with the hand
cocked upward. The right middle finger should be partially flexed,
relaxed, and poised to strike
5. Strike the pleximeter finger with the right middle finger (the plexor),
with a quick, sharp but relaxed wrist motion
6. Aim the strike at your distal interphalangeal joint.
7. Learn to identify five percussion notes which can be distinguished by
differences in their basic qualities of sound : intensity, pitch and
duration.
8. Comparing two areas of anterior chest
9. Identified the upper border of liver dullness (“Peranjakan”)
Auscultation :
1. instruct the patients to breath deeply through an open mouth
2. listen to breath sound with the diaphragm of your stethoscope
3. move your stethoscope from one side to the other and comparing
symmetrical areas of the lung
4. pattern of breath sound identified by their intensity, pitch, and
relative duration of their inspiratory and expiratory phases
5. the normal breath sounds are : vesicular, bronchovesicular and
bronchial
6. listen for any added or adventitious sound that are superimposed on
the usual breath sound. Adventitious sounds are crackles (rales),
wheezes and rhonchi
7. if you hear crackles, listen for the following characteristics
a. loudness, pitch and duration (summarized as fine or coarse
crackles)
b. number (few to many)
c. timing in respiratory cycle (inspiratory or expiratory)
d. location on the chest wall
e. persistence of their pattern from breath to breath
f. any change after a cough or a change in the patients position
10. if you hear wheeze or rhonchi , note their timing and location and do
they change with deep breathing or coughing
11. if you hear abnormally located bronchovesicular or bronchial breath

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 sound, continue on to asses transmitted voice sound.
12. With stethoscope, listen in symmetrical areas over the chest (Vocal
Resonance), as you :
g. ask the patient to say “ninety nine”. Normally the sound
transmitted through the chest wall are muffled and indistinct.
Louder and clearer voice sounds are called bronchophony
h. ask the patient to sal “ee” you will normally hear a muffled long
E sound. When “ee” is heard as “ay”. An E to A change
(egophony) is present.
i. Ask the patient to whisper “ninety nine” or “one – two – three “.
The whispered voice is normally heard faintly and indistinctly.
Louder, clearer whispered sounds are called whispered
pectoriloquy
Write Up
1. Write up all significant findings in the medical record
2. Conclusion
3. Hamdalah