Respiratory Exam

System/Body Area

Elements of Examination

Constitutional

• Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration,

5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)

• General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)

Head and Face

Eyes

Ears, Nose, Mouth and Throat

• Inspection of nasal mucosa, septum and turbinates

• Inspection of teeth and gums

• Examination of oropharynx (eg, oral mucosa, hard and soft palates, tongue, tonsils and posterior pharynx)

Neck

• Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus)

• Examination of thyroid (eg, enlargement, tenderness, mass)

• Examination of jugular veins (eg, distension; a, v or cannon a waves)

Respiratory

• Inspection of chest with notation of symmetry and expansion

• Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement)

• Percussion of chest (eg, dullness, flatness, hyperresonance)

• Palpation of chest (eg, tactile fremitus)

• Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)

Cardiovascular

• Auscultation of heart including sounds, abnormal sounds and murmurs

• Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)

Chest (Breasts)

Gastrointestinal

(Abdomen)

• Examination of abdomen with notation of presence of masses or tenderness

• Examination of liver and spleen

Genitourinary

Lymphatic

• Palpation of lymph nodes in neck, axillae, groin and/or other location

Musculoskeletal

• Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy and abnormal movements

• Examination of gait and station

Extremities

• Inspection and palpation of digits and nails (eg, clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes)

Skin

• Inspection and/or palpation of skin and subcutaneous tissue (eg, rashes, lesions, ulcers)

Neurological/

Psychiatric

Brief assessment of mental status including

· Orientation to time, place and person

· Mood and affect (eg, depression, anxiety, agitation)