1.1 Patient History & Physical Assessment
Key Takeaways
- Patient Data Evaluation is the largest content domain on the TMC Examination, so the bedside assessment skills in this section appear in roughly a quarter of scored items.
- Take history with the SAMPLE framework, then move head-to-toe: inspection, palpation, percussion, auscultation — in that fixed order.
- Normal breath sounds are vesicular (peripheral fields), bronchovesicular (mainstem bronchi), and bronchial (over the trachea); bronchial sounds heard peripherally signal consolidation.
- Adventitious sounds tested most often: fine and coarse crackles, wheezes, rhonchi, stridor, and pleural friction rub — match each to a mechanism.
- Tactile fremitus increases over consolidation and decreases over pneumothorax or effusion; percussion is hyperresonant over a pneumothorax and dull over fluid.
- Tracheal deviation moves AWAY from a tension pneumothorax or large effusion but TOWARD atelectasis or a pneumonectomy.
- Normal adult respiratory rate is 12-20 breaths/min; accessory-muscle use and paradoxical breathing are the earliest physical signs of impending respiratory failure.
- Digital clubbing reflects chronic hypoxemia (bronchiectasis, cystic fibrosis, lung cancer) — it is NOT a feature of uncomplicated asthma.
Why Assessment Anchors the Exam
The NBRC (National Board for Respiratory Care) credentials respiratory therapists through the TMC Examination (Therapist Multiple-Choice Examination): 160 items, 140 of them scored, completed in three hours. Passing at the low cut score of 86/140 earns the CRT (Certified Respiratory Therapist) credential; the high cut score of 92/140 earns CRT plus eligibility for the CSE (Clinical Simulation Examination), the second test required for the RRT (Registered Respiratory Therapist) credential.
Patient Data Evaluation and Recommendations is the single largest TMC content domain, so the bedside skills below are high-yield on both exams.
Patient Interview — the SAMPLE Framework
Gather history before you touch the patient. The SAMPLE mnemonic organizes a focused respiratory interview:
| Letter | Element | What to Ask / Document |
|---|---|---|
| S | Signs/Symptoms | Chief complaint, onset, severity, dyspnea on exertion, orthopnea, cough, sputum |
| A | Allergies | Drug, latex, environmental triggers |
| M | Medications | Inhalers, home oxygen, anticoagulants, recent steroids |
| P | Past medical history | COPD, asthma, CHF, prior intubation, smoking pack-years |
| L | Last oral intake | Critical before sedation, bronchoscopy, or intubation |
| E | Events leading up | Trigger, exposure, recent illness or travel |
Quantify smoking in pack-years (packs per day x years smoked); 20+ pack-years markedly raises COPD and lung-cancer probability and is a frequent distractor on exam stems.
Inspection
Visual data is collected first and continuously:
- Respiratory rate: normal adult 12-20/min; tachypnea >20, bradypnea <12.
- Pattern: Cheyne-Stokes (CHF, neuro), Kussmaul (deep/rapid, metabolic acidosis/DKA), Biot's (CNS injury), apneustic.
- Accessory-muscle use (sternocleidomastoid, scalenes) and intercostal/supraclavicular retractions signal increased work of breathing.
- Paradoxical (abdominal) breathing — the abdomen moves inward on inspiration — warns of diaphragmatic fatigue and impending failure.
- Chest shape: barrel chest and increased AP diameter in COPD; pectus excavatum; kyphoscoliosis (restrictive).
- Color: central cyanosis (lips, tongue) reflects ~5 g/dL deoxygenated hemoglobin; digital clubbing indicates chronic hypoxemia (bronchiectasis, CF, lung cancer) — not asthma.
- JVD and pedal edema point to right heart failure or cor pulmonale.
Auscultation of Breath Sounds
Auscultate systematically, comparing left to right, apices to bases.
| Type | Where Normal | Trap |
|---|---|---|
| Vesicular | Peripheral fields | Diminished = air trapping, effusion, obesity |
| Bronchovesicular | Between scapulae | — |
| Bronchial (tubular) | Over trachea | Heard peripherally = consolidation |
| Adventitious Sound | Character | Classic Cause |
|---|---|---|
| Fine crackles (rales) | High-pitched popping, end-inspiration, do NOT clear with cough | Pulmonary edema, fibrosis, pneumonia |
| Coarse crackles | Low, bubbling | Secretions, resolving pneumonia |
| Wheezes | Musical, mostly expiratory | Asthma, COPD, bronchospasm |
| Rhonchi | Low rumbling, clears with cough | Large-airway secretions, bronchitis |
| Stridor | High-pitched, INSPIRATORY, heard over neck | Upper-airway obstruction, croup, post-extubation edema |
| Pleural friction rub | Grating, both phases | Pleuritis, pulmonary embolism |
Palpation and Percussion
Palpation assesses tactile fremitus (vibration as the patient says "ninety-nine"): increased over consolidation, decreased over pneumothorax or effusion. Also check chest-expansion symmetry, subcutaneous emphysema (crepitus = air leak/barotrauma), and tracheal position — deviated AWAY from a tension pneumothorax or large effusion, TOWARD atelectasis or pneumonectomy.
Percussion maps air-versus-fluid: resonant is normal, hyperresonant means trapped air (pneumothorax, emphysema), dull means consolidation or effusion, and flat means a massive effusion. Build the habit of pairing each percussion note with its expected breath sound and fremitus — the NBRC loves three-finding stems that all point to one diagnosis.
Putting the Findings Together
Exam items rarely give one finding in isolation. They describe a cluster, and your job is to recognize the single condition that produces all of them at once. Three high-yield clusters:
- Tension pneumothorax: hyperresonant percussion, absent breath sounds, decreased fremitus, tracheal deviation away from the affected side, distended neck veins, and hypotension. The combination of deviation plus hypotension distinguishes it from a simple pneumothorax and demands immediate needle decompression rather than further imaging.
- Lobar consolidation (pneumonia): dull percussion, increased tactile fremitus, bronchial breath sounds heard peripherally, and late inspiratory crackles. Increased fremitus over dullness is the giveaway — fluid-filled airways transmit vibration better than air-filled lung.
- Large pleural effusion: flat or dull percussion, decreased fremitus, and diminished breath sounds with no tracheal pull toward the dull side (the trachea shifts away when the effusion is large). This separates effusion from atelectasis, which also gives dullness but pulls the trachea toward it.
Heart Sounds the RT Must Recognize
Cardiac auscultation overlaps with respiratory disease through right- and left-heart failure. S1 (mitral and tricuspid closure) and S2 (aortic and pulmonic closure) are normal. An S3 gallop is an early diastolic filling sound associated with volume overload and congestive heart failure and frequently accompanies the BNP elevation discussed later in this chapter. An S4 reflects a stiff, hypertrophied ventricle. A loud P2 (the pulmonic component of S2) signals pulmonary hypertension, tying the cardiac exam back to chronic lung disease and cor pulmonale.
When a stem pairs an S3, bibasilar crackles, JVD, and pedal edema, it is steering you toward cardiogenic pulmonary edema, not a primary lung process.
Documentation and Trending
A single assessment is a snapshot; the therapist's value lies in trending. Recording respiratory rate, accessory-muscle use, breath sounds, and SpO2 at consistent intervals lets you detect deterioration before a crisis. A rising rate with new accessory-muscle use and falling tidal volumes is the classic prelude to respiratory failure and a recommendation for escalated support, and the exam expects you to act on the trend rather than a lone reassuring number.
A respiratory therapist auscultates fine, popping sounds at the lung bases at end-inspiration that do NOT clear with coughing. These sounds are MOST consistent with:
A trauma patient has absent breath sounds and hyperresonant percussion on the right, with the trachea deviated to the LEFT. These findings together point to:
A high-pitched, predominantly INSPIRATORY sound heard loudest over the neck of a recently extubated patient most likely represents: