Respiratory and Thoracic

The first question is not “What lung sound is this?” It is “Is this patient moving enough air to remain safe?” Observe the patient before touching the stethoscope. Note position, facial expression, skin color, mental status, ability to speak, respiratory rate, depth, and visible effort. A patient who sits upright with shoulders elevated, braces the arms, speaks in short phrases, or recruits the sternocleidomastoid and scalene muscles is working to maintain ventilation. Count respirations for a full minute when the pattern is irregular. Tachypnea may be an early response to hypoxemia, metabolic acidosis, pain, fever, or anxiety; bradypnea, shallow breathing, or a slowing rate in an exhausted patient can signal respiratory muscle fatigue. A change in behavior may be more concerning than the patient’s stated dyspnea. Restlessness and anxiety can accompany early hypoxemia. New confusion, drowsiness, inability to stay awake, or a suddenly quiet patient may indicate worsening gas exchange or rising carbon dioxide rather than relief. Assess the patient’s ability to speak. Complete sentences suggest greater ventilatory reserve than single-word responses, but speech is not a substitute for respiratory...