Brittney Musgrave & Casey Kraft
Summary of Examination
1– Inspect the chest, front and back, noting thoracic landmarks for the following: (see p. 371)
– Size and shape (anteroposterior diameter compared with transverse diameter).
– Superficial venous patterns
– Prominence of ribs
2– Evaluate respirations for the following: (see p. 373)
– Rhythm or pattern
3– Inspect chest movements with breathing for the following: (see p.376)
– Use of accessory muscles
4– Note any audible sounds with respiration (ie: wheezes, stridor) (see p. 377)
5– Palpate the chest for the following: (see p. 377)
– Thoracic Expansion
– Sensations such as crepitus, grating vibrations
– Tactile Fremitus
6– Perform direct or indirect percussion on the chest, comparing sides for the following: (p 380)
– Diaphragmatic Excursion (movement of thoracic cavity during breathing)
– Percussion tone intensity, pitch, duration and quality
7– Auscultate the chest with the stethoscope diaphragm from apex to base comparing sides for
the following: (see p. 383)
– Intensity, pitch, duration, quality of expected breath sounds.
– Unexpected breath sounds (ie: crackles, wheezes, friction rubs)
– Vocal resonance (voice sounds heard on auscultation of the chest of an individual who
is vocalizing in some manner)
It is also important to ask the patient:
History of present illness:
(ie: Presence of coughing, shortness of breath, chest pain. If present,
specify onset, duration, pattern, aggravating factors, associated
symptoms, characteristics, severity, efforts to treat, most
Past Medical History of:
(ie: Use of oxygen or ventilation-assisting devices, chronic pulmonary
disease, other chronic disorders, immunizations against
pneumonia/influenza, thoracic/nasal/pharyngotracheal trauma or surgery,
hospitalizations for pulmonary disorders, and daily medications).
Family History of:
(ie: TB, cystic fibrosis, emphysema, allergies, asthma, atopic dermatitis,
malignancy, bronchiectasis, bronchitis, clotting disorders (risk for
Personal and Social History:
(ie: employment (exposure to chemicals or other pulmonary irritants),
home environment, tobacco use, exposure to respiratory infections,
nutritional status (wt. loss or obesity), use of herbal or other remedies,
regional or travel exposures, hobbies, use of alcohol & illegal drugs,
Tactile Fremitus– palpable vibration of the chest wall that results from speech or other
Crepitus– crackly or crinkly sensation that can be both heard and palpated.
Dyspnea– shortness of breath (SOB).
Bronchophony– greater clarity and increased loudness of spoken sounds.
Whispered pectoriloquy–increased loudness of whispering “1,2,3" while listening to the
posterior lung fields. Normally this should not be heard but if present it means there is
consolidation in lungs.
Egophony– increased intensity of the spoken voice with a nasal quality. Signifies lung
consolidation, primarily pleural effusion.
Orthopnea– shortness of breath that begins or increases when the patient lies down.
Paroxysmal nocturnal dyspnea– a sudden onset of SOB after a period of sleep; sitting upright is
Platypnea– dyspnea increases in the upright posture.
COPD-chronic obstructive pulmonary disease– nonspecific designation that includes a group of
respiratory problems in which coughs, chronic and often excessive sputum production and
dyspnea are prominent features. Ultimately, an irreversible expiratory airflow obstruction occurs.
This includes: chronic bronchitis, emphysema, asthmatic bronchitis, bronchiectasis, and even
Crackles (rales)– clicking, rattling or cracking noises heard on auscultation of the lungs caused
by the “popping open” of small airways and alveoli collapsed by fluid or exudate.
Rhonchi(sonorous wheeze)–loud, low coarse sounds like a snore most often heard continuously
during inspiration OR expiration; coughing may clear sound (usually means mucous
accumulation in trachea or large bronchi).
Wheeze (sibilant wheeze)– musical noise sounding like a squeak; most often heard continuously
during inspiration or expiration; usually louder during expiration.
Pleural friction rub– dry, rubbing, or grating sound, ussually caused by inflammation of pleural
surfaces; heard during inspiration OR expiration; loudest over lower lateral anterior surface.
Stridor– harsh grating or creaking sound due to any various form of obstruction of breathing
Asthma– chronic obstructive pulmonary disease characterized by airway inflammation and
generally resulting from airway hyperreactivity triggered by allergens, anxiety, URIs, cigarette
smoking or other environmental poisons.
Atelectasis– collapse of the alveoli.
Bronchitis– inflammation of the mucous membranes of the bronchial tubes.
Pleural effusion– accumulation of fluid in the pleural cavity.
Emphysema– chronic irreversible disease of the lungs characterized by abnormal enlargement of
air spaces in the lungs accompanied by destruction of the tissue lining the walls of the air spaces.
Lung abscess– acute or chronic infection of the lung, marked by a localized collection of pus,
inflammation, and destruction of tissue.
Pneumonia– excess fluid in lungs resulting from an inflammatory process.
Tuberculosis– potentially fatal contagious disease that can affect almost any part of the body but
is mainly an infection of the lungs. It is caused by a bacterial microorganism.
Pneumothorax– presence of air or gas in the pleural cavity.
Cor pulmonale– increase in bulk of the right ventricle of the heart generally caused by chronic
diseases or malfunction of the lungs. Can lead to heart failure.
Pulmonary embolism– obstruction of a pulmonary artery or a branch of it leading to the lungs by
a blood clot.
Vesicular breath sounds– low pitched, low intensity sounds heard over healthy lung tissue.
Bronchovesicular sounds– moderate pitch and intensity sounds heard over the major bronchi.
Bronchial sounds– highest intensity and pitch sounds heard over the trachea.
Biot respirations– irregularly interspersed periods of apnea in a disorganized sequence of
Kussmaul respirations– Rapid, deep, labored breathing.
Cheyne- Stokes Respirations– varying periods of increasing depth interspersed with apnea.
Sample Assessment Write Up
The patient is a 30 year old male who was admitted with consolidation pneumonia. Patient has
tachypnea, dyspnea, and shallow breathing. Lips and nail beds are slightly cyanotic. Over the
right upper lobe were increased fremitus, diminished breath sounds and dullness. Crackles were
heard upon auscultation over the right lobes.
Linda Jones is a 42-year old female who presents with a cough and dyspnea. Mrs. Jones was
brought to the ER by her daughter who states that her parents are going through a divorce.
Examination findings include: T: 98.4, P: 117, BP: 122/84, R: 25, diminished fremitus,
prolonged expirations, wheezes, and diminished lung sounds. She also states chest pain and a
feeling of tightness in her chest.
1) What is Mrs. Jones’s medical diagnosis?
2) What is the significance of Mrs. Jones’s daughter’s statement about their divorce?
3) What other questions should you include during the examination?
4) Name two pertinent nursing diagnoses.
5) What should you include in discharge teaching?
Multiple Choice Questions
1) Upon assessment of a patient with pneumonia one may find (Choose all that apply):
A. Nasal Flaring *
D shallow breathing*
2) The primary symptoms of asthma are (choose all that apply)
B increased secretions*
C mucosal edema*
3) Asking a patient to recite the numbers “99" or the words “Mickey mouse” helps to palpate
B whispered pectoriloquy
D tactile fremitus *
4) Dyspnea even at rest, barrel chest and thin appearance are all signs of
A emphysema *
D pleural effusion
5) What is the difference between orthopnea and platypnea?
A. orthopnea is sob when sitting upright
B orthopnea is sob while walking
C platypnea is sob while laying down
D platypnea is sob while sitting upright *
6) COPD can include all of these EXCEPT
A pneumothorax *
B asthmatic bronchitis
C cystic fibrosis
F chronic bronchitis
7) Auscultation of the lungs is best heard
A with the patient lying prone
B with the patient standing up
C with the patient sitting upright *
D with the patient lying on his or her side
8) Which breath sounds are heard over most lung fields, are low pitched, and heard over healthy
A vesicular breath sounds *
B bronchovesicular breath sounds
C bronchial breath sounds
9) Which breath sounds are highest pitch and are heard over the trachea?
A vesicular breath sounds
B bronchovesicular breath sounds
C bronchial breath sounds *
10) The rate and depth of respirations increase with all of the following EXCEPT:
A metabolic acidosis
C aspirin poisoning
D metabolic alkalosis *
11) Which pattern of respiration has varying periods of increasing depth interspaced with apnea?
D Cheyne- Stokes *
12) The costal angle measures:
A 30 degrees
B 45 degrees
C 60 degrees
D 90 degrees *
13) Which of the following statements about aa friction rub is true?
A low pitched sound heard on expiration only.
B high pitched sound heard on expiration only.
C low pitched sound heard on both inspiration and expiration *
D high pitched sound heard on both inspiration and expiration.
14) Greater clarity and increased loudness of spoken words are defined as:
A whispered pectoriloquy
B bronchophony *
D mediastinal crunch
15) Presence of air or gas in the pleural cavity signifies:
C pneumothorax *
16) Tactile fremitus is felt best at which intercostal space?
A 2nd *
17) Peripheral clues that may suggest pulmonary difficulty are (choose all that apply)
A clubbing of fingernails *
B nasal flaring *
C cyanosis of lips and nails *
D pursing of lips *
18) To auscultate the posterior lungs, ask the patient to
A sit erect with arms overhead
B sit upright
C lay supine on the examination table
D sit with head bent forward and arms folded in front to enlarge listening area*
19) Bronchophony, whispered pectoriloquy, and egophony are all forms of
B upper respiratory infections
C vocal resonance *
20) Tuberculosis is a viral infection, TRUE or FALSE?
B False *