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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