What is the usual order of the respiratory exam and what are the normal findings?

The Usual Order and Normal Findings of the Respiratory Examination

The standard respiratory examination follows a systematic approach of inspection, palpation, percussion, and auscultation, which allows for thorough assessment of respiratory function and identification of abnormalities. 1, 2, 3

Preparation for Examination

Before beginning the respiratory examination:

• Ask about smoking history, recent illness, medication use, and other relevant information 4
• Measure weight and height without shoes 4
• Have the patient loosen tight-fitting clothing for proper access to the chest 4
• Dentures should typically remain in place unless they are loose and may interfere with the examination 4
• Position the patient appropriately - typically sitting upright with head slightly elevated 4

Systematic Examination Approach

1. Inspection

• Observe the patient's breathing position, shape of thorax, and dynamics of respiration 5
• Note the breathing pattern, symmetry of chest expansion, and synchrony of rib cage and abdominal movements 5
• Look for signs of respiratory distress including use of accessory muscles, nasal flaring, or pursed-lip breathing 5
• Inspect the neck for jugular venous distention or tracheal deviation 5
• Check for cyanosis, finger clubbing, or other extrathoracic signs 5

2. Palpation

• Assess chest expansion by placing hands on the posterolateral chest wall and asking the patient to take a deep breath 5
• Evaluate tactile fremitus by placing the palms on the chest wall while the patient speaks 5
• Check for areas of tenderness, masses, or subcutaneous emphysema 5
• Palpate lymph nodes and integrate other extrarespiratory findings 5

3. Percussion

• Percuss systematically in a comparative manner (side-to-side) starting at the apices and moving downward 1
• Normal percussion produces a resonant sound over healthy lung tissue 1
• Dullness suggests consolidation or pleural effusion 1
• Hyperresonance may indicate emphysema or pneumothorax 1

4. Auscultation

• Listen systematically with the diaphragm of the stethoscope, comparing side-to-side 6
• Begin at the apices and move downward in a systematic pattern 6
• Ask the patient to take slow, deep breaths through an open mouth 6
• Normal breath sounds include:
  • Vesicular breath sounds: soft, low-pitched sounds heard over most of the lung fields 6
  • Bronchovesicular breath sounds: medium-pitched sounds heard over major bronchi 6
  • Bronchial breath sounds: loud, high-pitched sounds normally heard only over the trachea 6
• Note any abnormal sounds such as crackles, wheezes, or pleural rub 6

Common Pitfalls and Caveats

• Inadequate exposure of the chest may lead to missed findings 2
• Failure to compare corresponding areas on both sides of the chest can result in overlooking asymmetrical findings 2
• Room temperature should be comfortable to prevent shivering which can interfere with auscultation 2
• Background noise can mask subtle breath sounds - ensure a quiet examination environment 6
• Interobserver agreement about respiratory signs has been found to be generally low, emphasizing the importance of a systematic approach 5
• Proper positioning of the patient is crucial - incorrect positioning may alter breath sounds 2

Special Considerations

• For elderly patients, a lower threshold for thorough examination may be warranted as they are less likely to report symptoms compared to younger patients 4
• Children may require a modified approach with age-appropriate techniques to ensure cooperation 4
• In patients with suspected infection, appropriate infection control measures should be followed 4

By following this systematic approach to respiratory examination, clinicians can effectively assess respiratory function and identify abnormalities that may indicate underlying pathology.