LESSON 2
PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM
Section I. GENERAL APPROACH TO PHYSICAL ASSESSMENT
2-1.
PATIENT'S HISTORY
The patient's history, obtained by interviewing him, is the patient's view of his
health problems, general health condition, past medical history, family health history,
and profile of his personal and social life and well-being. Additionally, the patient's
history will show information the patient knows about his health, what is important in
terms of health care, and what he expects from the health care being asked for. Since
the interviewer is getting the information from the patient rather than observing him
directly, the patient history information is subjective information. Be sure to record this
information immediately and in an organized manner.
2-2.
CONDITIONS
The patient should be undressed to the waist. Be sure the examination is
conducted in a room with good light.
2-3.
PROCEDURE
a. Working from the top of the patient's body down, perform the examination
systematically from the head to the foot. In this way, you will be thorough and not miss
anything.
b. Compare the findings on one side of the body with the findings on the other
side of the body. In many instances, the body is bilaterally symmetrical; that is, the left
side of the body has many of the same parts as the right side of the body. The parts
are arranged as if the right side had been turned over.
c. Throughout the examination, try to visualize the structure of the body parts
underneath the tissues. In each region of the body, consider the function of the body
parts and be alert for any abnormalities.
d. Examine the patient's posterior thorax and lungs while he is in the sitting
position. The patient's arms should be folded across his chest so that the scapulae (the
shoulder blades) are partly out of the way. Then ask the patient to lie down while you
examine his anterior thorax and lungs.
MD0568
2-2