Chest Exam Lecture Powerpoint

Question 1

Adjacent to the sternal angle/angle of louis is the…

Answer 1

….2nd rib - beneath that is the 2nd intercostal space

Question 2

Importance of the costochondrial cartilage

Answer 2

Allows for mobility of the thorax upon inspiration

Question 3

Emergent pleural decompression/needle decompression of the thorax

Answer 3

Emergency procedure to treat patient with tension pneumothorax via large bore needle placed in the 2nd intercostal space mid clavicular line just over 3rd rib to convert a tension pneumothorax (characterized by air able to enter the cavity but not exit it causing it to grow and put pressure on organs every time it inspiration occurs) to a simple pneumothorax

Question 4

Importance of listening in all lung fields anteriorally and posteriorally

Answer 4

The orientation of the different lobes are situated that only doing the posterior lung fields only reaches the lower lobes, must do anterior and posterior to reach all areas

Question 5

Inspection on the chest exam (5)

Answer 5

• assess comfort (tripoding) and breathing pattern
• look for accessory muscle use
• assess skin color (lips and nails cyanosis or clubbing)
• look for barrel chest
• Look for tracheal deviations or spine/chest deformities (scoliosis, kyphosis, pectus excavatum or carinatum)

Question 6

Normal nail bed angle vs clubbed finger nail bed angle

Answer 6

160 degrees, greater than 180 degrees with enlargement and curving of nails

Question 7

Tripoding

Answer 7

Positioning of patient where they are leaning forward with hands on knees indicating dyspnea

Question 8

Barrel chest

Answer 8

Chronic expansion of the chest wall causing ap to lateral ratio to go from a healthy 1:2 to 1:1 often seen with conditions such as COPD

Question 9

Most common population to experience kyphosis and why?

Answer 9

Elderly, due to compression fractures

Question 10

Palpation on chest exam (3)

Answer 10

• Chest expansion (hands should move symmetrically, asymmetry may occur with air or fluid in pleural space)
• Tactile fremitus (ulnar surface of hand say 99 at diff points)
• palpation for pain (fracture or injury)

Question 11

Only pathophysiology associated with increased tactile fremitus, what is associated with decreased fremitus? (3)

Answer 11

• Consolidation of the lungs associated with pneumonia

- Pleural effusion, COPD, pneumothorax, etc.

Question 12

Increased fremitus mech of action, decreased fremitus mech of action

Answer 12

• Consolidated lungs are hardened and full of solid material in the lobe (pus, blood, mucus all hardens)
• they conduct vibration better than airfilled lung tissue
• Pleural effusion sees fluid buildup in the pleural space around the lung
• sound is not transmitted as easily due to a muffler over the lung itself

Question 13

Pleximeter vs plexor

Answer 13

Pleximeter is the DIP or placed against patient with varying pressure depending on how loud the sound is wanted to be, plexor is the striking finger

Question 14

The 5 notes of percussion of the chest and what they indicate

Answer 14

Flat - effusion
Dull - pneumonia
resonant - healthy
hyperresonant - COPD, pneumothorax
tympanic - pneumothorax

Question 15

Percussion on chest exam (2)

Answer 15

• Percuss in ladder pattern
• measure diaphragmatic excursion (find diaphragm by percussing down till dull, have patient inhale, percuss down till dull, mark, have patient exhale, percuss up till dull and mark, should measure 3-5 cm)

Question 16

Auscultation on chest exam (3)

Answer 16

• Patient lean forward arms folded over chest with head bent forward
• Use diaphagm in ladder pattern
• Have patient breath slowly THRU MOUTH after coughing 1 or 2 times to clear field

Question 17

Best place to hear right middle lobe of right lung on auscultation

Answer 17

Lower right axilla

Question 18

Normal lung sounds heard on auscultation and the 2 non normal ones

Answer 18

Normal:
-Vesicular (soft inspiratory sound with short expiratory phase)
Non-normal:
-bronchovesicular (intermediate intensity, inspiration and expiration equal in length, indicates fluid filled or solid lung tissue)
-bronchial (loud expiration which is longer following gap in between, normally heard over manubrium but everywhere else indicates consolidated lung)

Question 19

Absence of lung sounds upon auscultation indicates 1 of these 3 conditions

Answer 19

pleural effusion, severe emphysema, or severe asthma attack

Question 20

3 Adventitious lung sounds

Answer 20

1) Crackles (rales) - scratchy brief sounds assoc. with fluid in alveolar and interstitial spaces, bilateral in CHF, restricted to specific lobe in pneumonia, diffuse in pulmonary fibrosis
2) Wheezes - whistling noises on expiration and sometimes inspiration when airways are narrowed by bronchoconstriction or secretions, suggests narrowed airway such as mechanical obstruction, asthma, copd, or bronchitis
3) rhonchi - secretions that collect in upper airways producing gurgling noise that is low pitched with snoring quality indicative of copd and bronchitis

Question 21

Increased transmission of voice sounds suggest that an air filled lung has become…

Answer 21

….airless

Question 22

Bronchophony

Answer 22

Test of transmitted voice sounds, where normal sounds transmitted thru chest wall should be muffled but in areas where transmitted clearly indicates consolidation (have the patient say 99)

Question 23

Egophony

Answer 23

Test of transmitted voice sounds, where alteration of voice saying Ee heard as ayy indicates consolidation in that area

Question 24

Whispered pectorliquy

Answer 24

Test of transmitted voice sounds, where normal sounds should be hard to hear but sounds louder or clearer indicate consolidation (have the patient whisper 99)

Question 25

Importance of doing entire lung exam

Answer 25

By combining outcomes of different signs and tests can narrow down diagnosis more specifically

Question 26

Thyroid cartilage

Answer 26

Adam’s apple, prominent landmark for finding location of larynx

Question 27

Cricoid cartilage

Answer 27

The 1st thickened tracheal ring located beneath the thyroid cartilage, useful landmark when performing emergent cricothyrotomy or cricoid pressure

Question 28

The suprasternal notch forms the articulation point of the…

Answer 28

…clavicles to the manubrium

Question 29

Ribs 1-_ connect directly to the body of the sternum, then ____ are attached via cartilage, and ___ are hanging

Answer 29

5, 6-10, 11 and 12

Question 30

Chest tube insertion

Answer 30

Procedure done to treat all types of pneumothorax thru incision at 4th to 5th intercostal space at anterior axial line to evacuate air allowing for lung to inflate

Question 31

Best place to hear lower lobes of lungs on auscultation

Answer 31

3/4 of lower posterior field

Question 32

Best place to hear upper lobes of lungs on auscultation

Answer 32

Anterior chest or upper 1/4 of posterior field

Question 33

Stridor

Answer 33

Wheezing on inspiration associated with mechanical obstruction of trachea