1. Know the framework for history taking and physical examination of the respiratory system
-cough duration and onset, dry or moist, sound?
-sputum colouration and smell?
-haemoptysis :(coughing up blood) volume?
-dyspnoea: (breathlessness) triggers, duration and variability?
-wheeze :(whistling noise from the chest)maximal during expiration
-chest pain pleura and airways are the source of pain
-sleep apnoea : (cessation of inspiratory muscle activity)
-hyperventilation : (anxiety, increased resp rate)
-In deciding treatment, it is crucial to know what medication the patient is already on. Find out their
-past history (previous case lung diseases, tests/surgical ?)
- occupational history ***(exposure to asbestos/dust in mine industry and factories?)
- social history (smoker –amount/day?, alcohol, drugs?)
-family history (asthma, cystic fibrosis, lung cancer?)
Positioning the patient
- the patient should be undressed to the waist. Often sitting over the edge of the bed. In addition,
observe the patient’s general appearance by counting the respiratory rate at rest (range between
16-25) + temperature and blood pressure.
-Examine their hands (examination begins here) : clubbing, staining, wasting and weakness, flapping
tremor (asterixis) (see page 118 Tally & O’Connor)
-Face: nose (polyps?), skin changes (wrinkled and leathery for a smoker), mouth, eyes (Horner’s
syndrome ), sinuses
-Trachea : feel for the trachea at the suprasternal notch – deviated or central?
-Chest: Shape and symmetry of chest : “pigeon chest” )protrusion of the sternum and costal
cartilages, “funnel chest” (localised depression of lower sternum, “Harrison’s sulcus”(linear
depression where costal part of diagraph attaches), kyphosis and scoliosis
Have the left hand on the chest wall and strike the middle phalanx with the middle finger of the
-Percussion over solid areas like the liver or consolidated and collapsed lung will produce dull
-Percussion over fluid filled areas (e.g. pneumonia, pleural effusion )produces an extremely dull and
thud like sounds
- Percussion over the normal lung produces a resonant note low pitched and hollow sounding.
Work from the top part of the chest, downwards and compare the sounds heard to the right and left
Auscultation breath sounds
Using the diaphragm of the stethoscope, listen in on specific parts of the chest wall for the quality of
breath sounds, bronchial breath sounds, and the intensity of breath sounds. As well as additional
sounds (wheezes, crackles, pleura rub).
Posterior Place hands firm around the inferior chest wall having the thumbs meet roughly at the
midline. Don’t have them touching the chest wall so they are able to move with inspiration.
Anterior place hands along the costal margins with hands along the lateral part of the rib cage.
Get the patient to inhale deeply. Watch for the thumbs to separate as the lung expands. Feel for
range of symmetry.