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Anatomy and Physiology

Health History

  1. Current Health Status
    • - shortness of breath
    • - cyanosis
    • - cough
    • - sputum
    • - chest pain
  2. Past Health History
    • - prior lung disease
    • - exposure to respiratory disease
    • - allergies
    • - smoking
    • - OTC nasal sprays or medications
    • - use of oxygen
    • - vaccinations



Remove all clothing to waist. Sit on an exam table or stand.


  1. Shape of chest -
    • A. AP Diameter - (Antero-posterior diameter)
    • B. Barrel Chest - AP diameter compared to transverse diameter is 1:1
    • C. Pigeon Breast (Pecus carinatum) - AP diameter is increased
    • D. Funnel Breast - (Pecus excavatum)
    • E. Kyphosis
    • F. Poker Spine
    • G. Scoliosis
    • H. Lordosis

  2. Slope of Ribs - normally ribs are inserted into the spine at a 45E angle and inserted into the costal angle at a 45E angle.

  3. Abnormal Retraction of Interspaces During Inspiration

    • A. Substernal retractions
    • B. Intercostal retractions
    • C. Suprasternal retractions

  4. Pattern of Respiration
    • A. Men & women - breathe diaphragmatically
    • Women - breathe thoracically or costaly

  5. Rate Depth, Type and Rhythm of Breathing
    • A. Eupnea, 16-20 BPM
    • B. Tachypnea, respirations over 20 BPM
    • C. Bradypnea, respirations under 10 BPM
    • D. Apnea, absence of respirations
    • E. Hyperpnea, increase in depth of respirations
    • F. Cheyne-Stokes, altering hyperpnea and shallow respirations, followed by periods of apnea.
    • G. Biot's, shallow breathing interrupted by apnea
    • H. Kussmauls, increase in rate and depth
    • Apneustic, long inspiration, short expiration

  6. Use of Accessory Muscles.
    • A. Sternocleidomastoid muscle
    • B. Scalenus
    • Trapezius

  7. Symmetry of Chest Expansion

  8. Lips, Nailbeds, Nares


  1. Identify Areas of Tenderness, Lesions, Masses, or Crepitation

  2. Respiratory Excursion. (Thoracic expansion) Can be assessed in anterior or posterior chest.

  3. Tactile Fremitus (vocal fremitus) - client says "99" while examiner palpates the thorax using palmar surface of fingers or ulnar aspect of hand.

    • A. Normal fremitus
    • B. Increased vocal fremitus
    • C. Decreased or absent vocal fremitus

  4. Vibration (fremitus) During Quiet Inspiration and Expiration

  5. Palpate for Tracheal Deviation.


  1. Percussion penetrates to a depth of approximately 5-7 cm. It is used to determine the relative amounts of air, liquid, or solid material in the underlying lung.
    • Resonance - loud, low pitched hollow sound of a long duration.

  2. Abnormal percussion notes:

    • Hyperresonance - occurs with increased amounts of air. Loud, low-pitched booming sound with a long duration.

    • Dullness - occurs with fluid, pus, consolidation, or tumors. Medium soft intensity with a thud-like sound.

    • Flatness- large amount of fluid over an area with little underlying air. (Pleural effusion). Soft, high-pitched sound with a very short duration.

  3. Diaphragmatic excursion


  1. Symmetrical Areas Should be Compared in Regard to

    • Pitch
    • Intensity
    • Quality
    • Duration
    • Presence of Adventitious Breath Sounds.

    Instruct client to breathe slightly more deeply and slowly than normal respiration. Client should breathe through open mouth.

    Sound Duration of inspiration and expiration Diagram of sound Pitch Intensity Normal Location Abnormal Location
    Vesicular Inspiration > expiration 5 : 2 Low Soft Peripheral lung Over trachea and sternum
    Broncho-vesicular Inspiration = expiration 1 : 1 Moderate Moderate First and second intercostal spaces at the border over major bronchi Peripheral lung
    Bronchial (tubular) Inspiration < expiration 1 : 2 Pause between inspiration and expiration High Loud Over trachea Lung areas

  2. Changes in Normal Breath Sounds

    • A. Deep breathing changes normal vesicular sounds to bronchovesicular sounds
    • B. Breathing through the nose will alter normal breath sounds
    • C. Fluid filling the alveoli will convert vesicular sounds to bronchovesicular sounds (early pneumonia).
    • D. Large amounts of fluid collecting will change vesicular to bronchial sounds (lung consolidation).
    • E. No breath sounds
      • obstructed bronchus
      • pneumothorax
      • fractured ribs with splinting
      • obesity
      • barrel chest
        • thickened pleura
        • air and fluid in pleural place

  3. Egophony - when listening over a normal peripheral lung you will hear the sound "eee" when the patient voices "eee." When the lung is compressed by fluid (pleural effusion), you will hear the sound "aye."

  4. Adventitious Sounds

    • A. Crackles (rales)
      1. Fine - high pitched
      2. Medium
      3. Coarse - low pitched
    • B. Wheezes
      1. Sonorous (coarse) - low pitched
      2. Sibilant (wheezes) - high pitched (usually occurs during expiratory phase of respiration. Inspiratory wheezes indicate severe narrowing of the airway.)
          a. monophonic wheezes
          b. polyphonic wheezes

  5. C. Rhonchi (gurgles)

  6. D. Friction rub - loud dry creaking or grating sound heard best over lower anterolateral thorax

  7. E. Stridor - an inspiratory wheeze that is louder over the neck than the thorax.

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