High-yield Med Skills - Respiratory

Respiratory Review of Systems By Luis Martinez, D.O.

1. General a. Exercise intolerance 2. Skin a. Cyanosis b. Clubbing c. Skin Ulcers d. Stasis Dermatitis (brownish pigment discoloration) 3. Head 4. Eyes 5. Ears 6. Nose and Sinuses 7. Throat 8. Neck 9. Breast 10.Respiratory a. Cough i. Productive? And of what? b. Wheezing c. Hemoptysis d. Shortness of breath e. Pain with respiration 11.Cardiovascular a. Chest pain i. Radiation? b. Palpitations c. Shortness of breath i. Dyspnea (shortness of breath inappropriate to exertion) ii.Orthopnea (shortness of breath when the patient is recumbent) iii.Paroxysmal nocturnal dyspnea (orthopnea that awakens patient) d. Dizziness i. Posturally related? e. Syncope f. Edema g. Claudication 12.Gastrointestinal

a. Dyspepsia b. Epigastric or hypogastric (e.g. upper abdominal) pain c. Excessive eructation 13.Urinary 14.Male Genital 15.Female Genital 16.Peripheral Vascular a. Cold extremities 17.Musculoskeletal a. Pain with respiration 18.Psychiatric 19.Neurological 20.Hematological a. Easy bruising/bleeding 21.Endocrine a. Heat or cold intolerance ***Obtain vitals at the end of the ROS***

Respiratory Exam 1. General Survey a. Inspection i. Patient’s color and digits for cyanosis, clubbing ii.Listen to the patient’s breathing without a stethoscope for stridor, wheezing, and other abnormal sounds 1. Note rate ,rhythm, depth, and effort of breathing including prolonged expiratory phase iii.Observe shoulders and neck for use of accessory muscles of respiration 1. Assess respiratory effort iv.Note abnormal motion of the chest wall and the general shape 2. Examination of the Posterior Chest a. Inspection i. Deformities or asymmetry ii.Abnormal intercostal or supraclavicular retractions iii.Delayed respiratory movement on one or both sides b. Palpation i. Tenderness ii.Skin abnormalities such as masses or sinus tracts iii.Test chest expansion 1. Place thumbs @ level of 10th ribs with fingers grasping the lateral rib cage 2. Ask the patient to inhale deeply and watch the distance between your thumbs as they move apart

iv.Tactile fremitus 1. Simultaneously use the ball or ulnar surface of both hands to compare sides 2. Ask patient to repeat “one-one-one” 3. Identify and locate areas of increased, decreased, or absent fremitus

c. Percussion i. Patient keeps both arms crossed in front of the chest ii.Percuss symmetrical areas bilaterally in a “ladder” technique (same as locations for feeling fremitus) 1. Identify abnormal percussion notes

iii.Assess diaphragmatic excursion 1. During quiet respiration, percuss downward in progressive steps until dullness clearly replaces resonance = level of diaphragm during quiet respiration

2. Determine distance between level of dullness of full expiration and the level of dullness on full inspiration = diaphragmatic excursion, normally about 5-6 cm. d. Auscultation i. Patient is breathing through their mouth for breath sound auscultation ii.Auscultate symmetrical areas bilaterally in a “ladder” technique (same as locations for feeling fremitus) 1. Listen for sounds heard distant from locations heard normally

2. Listen for adventitious sounds

iii.Auscultate transmitted voice sounds 1. Listen to symmetric areas over the chest wall a. Ask patient to say “ninety-nine” i. Bronchophony: louder, clearer voice sounds b. Ask patient to say “ee” i. Egophony: E-to-A change c. Ask patient to whisper “ninety-nine” i. Whispered pectoriloquy: louder, clearer whispered sounds 3. Examination of the Anterior Chest a. Patient supine

b. Inspection i. Deformities or asymmetry ii.Abnormal retractions iii.Delayed respiratory movement on one or both sides c. Palpation i. Tenderness ii.Further assess chest wall expansion

iii.Assess tactile fremitus 1. Compare both sides of the chest using the ball or ulnar surface of the hand 2. Ask patient to repeat “one-one-one” 3. Identify and locate areas of increased, decreased, or absent fremitus

d. Percussion

i. Percuss symmetrical areas bilaterally in a “ladder” technique (same as locations for feeling fremitus) ii.Percuss the upper border of liver dullness e. Auscultation i. Patient is breathing through their mouth for breath sound auscultation ii.Auscultate symmetrical areas bilaterally in a “ladder” technique (same as locations for feeling fremitus) 1. Listen for sounds heard distant from locations heard normally 2. Listen for adventitious sounds 3. Auscultate transmitted voice sounds a. Listen to symmetric areas over the chest wall i. Ask patient to say “ninety-nine” 1. Bronchophony: louder, clearer voice sounds ii.Ask patient to say “ee” 1. Egophony: E-to-A change iii.Ask patient to whisper “ninety-nine” 1. Whispered pectoriloquy: louder, clearer whispered sounds