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HEENT/Respiratory Assessment

• Common chief complaints include: Shortness of breath (dyspnea), hypoxia vs.
hypoxemia (Always think of hypoxemia (emia - blood) and hypoxia as deficient tissue
oxygenation), Pleuritic chest pain (pain upon respiration or upon breathing), Cough,
• Finish the head if not a focused Respiratory exam
• Inspect sclera, conjunctiva
• Inspect oral mucosa and pharynx
• Percuss (direct) sinuses
• Palpate lymph nodes: submental, submandibular (lymph nodes found below the
mandible), auricular, cervical, supraclavicular
• Inspect trachea (midline ?)
• To check for jaundice, check the heart palate of the mouth
• Thorax
• Inspect ratio (should be 2:1), accessory muscle use, chest expansion
• Palpate for tactile fremitus (best over major airways): somewhere near the
• Percuss (indirect) same spots you will use for auscultation
• Auscultate
• At least once in each lobe, front (4) and back (6)
• Side to side comparison
• Throughout breath
What am I listening for
“normal” adventitious
Inspiration Expiration
V Bubbling Crackles Rhonchi
V Whistling Stridor Wheeze

Oh by the way:
Old people call crackles: Rales

Comprehensive Pulmonology
Anatomy: Airway
• Upper conductive portion of
airway consists of oral and
nasal cavity, pharynx, larynx
• Lower portion starts at
trachea, dividing into two
bronchi, which further divide
into multiple bronchus to
supply 5 lobes of lung with air
• This portion of airway
essentially a dead space for
air, but contains mucous cells
and cilia to clear material
Anatomy: Airway
• Smooth muscle in bronchus
stimulated by Beta 2 agonists
to relax (dilate)
• Purpose is to deliver Oxygen
to terminal respiratory units
and to clear Carbon dioxide,
as well as to clean out foreign
• Note the position of Right
mainstem bronchi: Easier to
aspirate into right lobe, and
when a patient is supine, the
right upper lobe is most
Anatomy: Alveoli
• Terminal Units consist of many
bronchioles and alveoli, whose
responsibility it is to exchange air
• Alveoli are spherical sacs wrapped in
pulmonary capillaries
• Alveoli contain macrophage to clean
out foreign matter
• Alveoli also contain surfactant
producing Type II pneumocytes,
whose responsibility it is to keep
alveoli open during expiration (think
how hard an empty balloon is to blow
Anatomy: Pleura
• Lungs encased in a
visceral pleura that lies
inside of the parietal
pleura lining chest wall
• Lubricated layer allows
movement of lungs during
expansion and relaxation
• Attached to chest wall
and diaphragm to pull
lungs open
• This potential space can
fill with air
(pneumothorax) or fluid
Pathophysiology: Upper Respiratory Tract
Sinusitis: Infection of Sinus’ often
from similar bugs to OM
• s/s: positive sinus tap, h/a
Rhinitis: Viral or Allergic
inflammation of nasal cavity
• s/s: Pale turbinates, clear
Pharyngitis: Viral or Strep
Infection of pharynx; If Strep
think of post sickness
complications like Rheumatic
Fever or Glomerulonephritis
• s/s:Sore throat, dysphagia, fever
(low grade if viral, high grade if
bacterial; purulent if bacterial)
• Caution for subsequent
Rheumatic Fever or Glomneph
Common Respiratory Signs/Symptoms
Lung Abnormalities
Common Respiratory Signs/Symptoms
• Facts: Subjective feeling of ‘short of breath’, range from mild on exertion to
severe at rest; Begins during exercise and can be associated with body
• Orthopnea: Dyspnea upon lying down from pulm congestion where
abdominal contents put pressure on diaphragm and ↓ lung clearance
• Paroxysmal Nocturnal Dyspnea: Pt awakens w/SOB at night from
left HF
• S/S: Nasal flaring, accessory muscle use, retractions (intracostal in
pneumonia; supracostal with upper obstruction)
• Facts: Lack of spontaneous respirations
• Cause: Can occur spontaneously at night (OSA) causing fatigue, mood
changes, heart problems or death; Can also occur in COPD patients being
administered high flow oxygen
Common Respiratory Signs/Symptoms
Pleuritic Chest Pain
• Pain on inspiration, often unilateral and localized
• Helpful assessment to document as can help rule out cardiac cause
of chest pain and focus on respiratory exam
• Causes:
• Pulmonary Embolism
• Pneumonia
• Pneumothorax
• Pleural Effusion
• Pleurisy
• Pericarditis
S/S: Pleuritic chest pain, fever,
cough, dyspnea, crackles,
decreased breath sounds,
malaise, bronchial breath sounds
(this is around the vesticular),
dullness on percussion
Tuberculosis Pathophysiology
• Most common cause of death due to
infection worldwide
• S/S: Low grade fever, night sweats, weight loss, malaise, and
hemoptysis (coughing up blood)
Heart Failure
• Left sided HF many symptoms and few signs
• Symptoms: Dyspnea from pulmonary congestion;
Orthopnea (can’t breath upon lying down); Paroxysmal
nocturnal dyspnea (awake after falling asleep w/dyspnea);
Nocturnal cough; Confusion and memory problems;
Diaphoresis with cool extremities at rest
• Right sided failure: Many signs, few symptoms
• Symptoms: Nocturia, Orthopnea
• Signs: Peripheral pitting edema (A), JVD (jugular vein
distention) (B), HSM, Ascites (C), right sided heave,
increased ICP

Pulmonary Edema
• One of the most common complications of heart failure; Also seen with
ARDS, fluid overload, liver disease, etc.
•S/S: Intermittent wheezing, chest tightness, or cough;
S/S worse at night

Asthma: note the combination

of edema, mucous and
• Chronic Bronchitis: Productive
cough, Wheeze, cyanosis,
Polycythemia, cor pulmonale; Pink
• Emphysema: Barrel chest 1:1 ratio,
Dyspnea, Flat Diaphragm, Costal
Angle > 90, prolonged expiration; Blue
Bloater (cannot get enough oxygen)

Pleural Effusion
• s/s: dyspnea, orthopnea,
pleuritic chest pain, fever,
often assymptomatic

S/S: Dyspnea, Pleuritic chest pain,
anxiety, absent tactile fremitus,
hyperresonance on percussion,
decreased to absent breath sounds
Tension s/s: Shift of trachea away from
affected side; Very Bad! Decompress

Tension vs
Pulmonary Embolism
s/s: Acute Dyspnea, Pleuritic chest pain, tachypnea, tachycardia, crackles or
wheezing; Less commonly may see cough, hemoptysis, altered mental status,
hypotension,, syncope

Infarcted area of lung due to Typical Donut Sign on CT angiography

massive PE