Exam 1 - Thorax and Lungs Physical Exam

Question 1

2nd intercostal space

Answer 1

Needle insertion/ decompression of tension PTX

Question 2

4th intercostal space

Answer 2

Chest tube insertion

Question 3

When you document your findings in thorax, how are they described? What two dimensions?

Answer 3

The vertical axis and circumferentially.

To denote vertical locations, count the ribs and interspaces; sternal angle is the best guide!

Question 4

To denote findings around the circumference of the thorax, imagine a series of vertical lines. Name them!

Answer 4

ANTERIOR VIEW: Midsternal line, midclavicular line, anterior axillary line

LATERAL VIEW: Anterior axillary line, medial axillary line, posterior axillary line

POSTERIOR VIEW: Vertebral line in middle and scapular line in the middle of the scapula.

Question 5

How is the left lung divided?

Answer 5

The left lung is divided into upper and lower lobes

Question 6

How is the right lung divided?

Answer 6

The right lung is divided into upper, middle, and lower lobes

Question 7

What is the oblique or major lung fissure?

Answer 7

Each lung is divided roughly in half by an oblique (major) fissure

Question 8

What is a minor lung fissure?

Answer 8

The right lung is further divided by the horizontal (minor) fissure; only present in right lung! Bc right lung has three lobes

Question 9

Where does the trachea branch?

Answer 9

The trachea bifurcates at sternal notch (anteriorly), and T4 (posteriorly).

Question 10

Supraclavicular

Answer 10

Above the clavicles

Question 11

Infraclavicular

Answer 11

Below the clavicles

Question 12

Interscapular

Answer 12

Between the scapulae

Question 13

Infrascapular

Answer 13

Below the scapulae

Question 14

Bases of the lungs

Answer 14

The inferior-most portions

Question 15

Apices of the lungs

Answer 15

The superior-most portions

Question 16

Common Complaints of Thorax/Lungs

Answer 16

Chest pain
Shortness of breath
Wheezing
Cough
Blood-streaked sputum

Question 17

When a patient has chest pain, it is EXTREMELY important that you:

Answer 17

Ask the patient to point to the location of the pain

Attempt to elicit all seven attributes of the patient’s symptom

Question 18

Chest pain is complicated because:

Answer 18

Aside from lung conditions, chest pain may arise from cardiac, vascular, gastrointestinal, musculoskeletal, or skin pathology; it is also commonly associated with anxiety!

Other surrounding structures may also irritate the parietal pleura, causing pain.

**Difficult to find source?

Question 19

How to ask about Shortness of Breath (Dyspnea)?

How do you determine severity?

Answer 19

Dyspnea is not painful, but an uncomfortable awareness of breathing that is inappropriate to the level of exertion.

Begin assessment with a broad question, such as, “Have you had any difficulty breathing?”

Determine the severity of dyspnea based on the patient’s daily activities = dyspnea on exertion.

Question 20

What is wheezing?

Answer 20

Wheezes are musical respiratory sounds that may be audible to the patient and to others

Question 21

What do you ask when your patient has a cough?

Answer 21

1. Ask whether the cough is dry or produces sputum, or phlegm
2. Ask the patient to describe the volume of any sputum and its color, odor, and consistency

Question 22

What is a cough?

Answer 22

Cough is typically a reflex response to stimuli that irritate receptors in the larynx, trachea, or large bronchi; it may sometimes be cardiovascular in origin.

Question 23

What is Hemoptysis?

Answer 23

Hemoptysis is the coughing up of blood from the lungs; it may vary from blood-streaked phlegm to frank blood

Question 24

What do you ask when a patient has hemoptysis?

Answer 24

Ask the patient to describe the volume of blood produced as well as other sputum attributes
Try to confirm the source of the bleeding by history and examination before using the term “hemoptysis”; blood may also originate from the mouth, pharynx, or gastrointestinal tract

Question 25

Tobacco cessation is the leading cause of _____.

Answer 25

Smoking is the leading cause of preventable death in the United States

Question 26

Remember the 5 A's that regard smoking addiction.

Answer 26

ASK, ADVISE, ASSESS, ASSIST, ARRANGE Ask about smoking at each visit Advise patients regularly to stop smoking using a clear, personalized message Assess patient readiness to quit Assist patients to set stop dates and provide educational materials for self-help Arrange for follow-up visits to monitor and support patient progress

Question 27

Who should get a pneumococcal vaccine?

Answer 27

Adults ≥65 years ◗ Children and adults from 2 years to 64 years old with chronic illnesses spe- ci cally associated with increased risk of pneumococcal infection (sickle cell anemia, cardiovascular and pulmonary disease, diabetes, cirrhosis, and leaks of cerebrospinal uid) ◗ Smokers from 19 years to 64 years old ◗ Anyone with or about to receive a cochlear implant ◗ Adults and children older than 2 years who are immunocompromised (including from HIV infection, AIDS, steroids, radiation, or chemo).

Question 28

Who should get an influenza vaccine?

Answer 28

Adults with chronic pulmonary conditions, those immunosuppressed or morbidly obese, chronic med conditions ◗ Health care personnel ◗ pregnant women (pregnant during flu season) ◗ Residents of nursing homes ◗ American Indians and Alaska natives Household contacts and caregivers of children 5 years of age and younger (especially infants age 6 months and younger) and of adults 50 years of age and older with medical conditions placing them at higher risk for complications of influenza

Question 29

Respiratory ROS

Answer 29

``` Cough Sputum (color, quantity) Dyspnea Hemoptysis Wheezing Asthma Bronchitis Emphysema Pneumonia Tuberculosis Pleurisy Last CXR ```

Question 30

General Technique of Lung and Thorax Exam

Answer 30

Examine the anterior and posterior thorax and lungs while the patient is sitting May also examine the anterior thorax and lungs with the patient laying supine Compare one side of the thorax and lungs with the other Proceed in an orderly fashion: inspect, palpate, percuss, and auscultate

Question 31

Inspection of Lungs/Thorax

Answer 31

Initial survey of respiration and the thorax Observe the rate, rhythm, depth, and effort of breathing Inspect for any signs of respiratory difficulty Patient’s color (pale, cyanotic), patient’s breathing (labored, retractions, use of accessory muscles, pursed lips) Inspect the patient’s neck (distended veins, use of accessory muscles) Inspect the shape of the chest AP diameter (increases with age) vs Lateral diameter

Question 32

Chest Expansion

Answer 32

Test chest expansion: place thumbs at the level of the 10th rib with fingers loosely grasping and parallel to the lateral rib cage; watch the distance between the thumbs as they move apart during deep inspiration

Question 33

Tactile Frenitus

Answer 33

Note tactile fremitus = palpable vibrations as the patient is speaking; ask the patient to say “99”

Question 34

Percussion of Thorax

Answer 34

Percussion - Perform from side to side to assess for asymmetry Strike using the tip of your tapping finger Use middle finger of one hand (pleximeter), only DIP in contact with chest Use middle finger tip on other hand (plexor), 90 deg angle to pleximeter Use the lightest percussion that produces a clear note

Question 35

Pleximeter

Answer 35

Finger that dips in contact with chest during percussion

Question 36

Plexor

Answer 36

Finger that taps for percussion

Question 37

Why is percussion useful?

Answer 37

Percussion helps establish whether the underlying tissues (5-7 cm deep) are air-filled, fluid-filled, or solid

Question 38

Flat sounds from percussion

Answer 38

Flat sounds - fluid consolidation, such as a large pleural effusion --- usually blood, mucus, fluid

Question 39

Dull sounds from percussion (decrease of resonance)

Answer 39

Dull sounds = a solid sound, such as the liver, lobar pneumonia Dull=SOLID - diaphragm in diaphragmatic excursion has a DULL sound.

Question 40

Resonant Sounds from percussion

Answer 40

Resonant sounds = a loud, clear, deep sound, such as with normal lungs, simple bronchitis

Question 41

Hyperresonant sounds from percussion

Answer 41

Hyperresonant sounds = exaggerated lung sounds, such as with abnormal pulmonary conditions (COPD)

Question 42

Tympanic sounds from percussion

Answer 42

Tympanic sounds = absent sounds, such as a large PTX (from air filling the chest cavity in front of the lungs which causes lung to collapse).

Question 43

Bell of stethoscope

Answer 43

Picks up low pitch, ex: bruits and heart murmurs

Question 44

Diaphragm of stethoscope

Answer 44

Picks up higher pitched sounds

Question 45

Auscultation of the chest

Answer 45

The most important examination technique for assessing air flow through the tracheobronchial tree (and surrounding lungs/pleura) Listen to the breath sounds with the diaphragm of a stethoscope after instructing the patient to breathe deeply through an open mouth Use the same pattern as for percussion, moving from one side to the other and comparing symmetric areas of the lungs Listen to at least one full breath in each location Do not move stethoscope until patient fully exhales

Question 46

Normal breath sounds: Vesicular sounds

Answer 46

Vesicular = SOFT and low pitched; usually heard over most of both lungs

Question 47

Normal breath sounds: Bronchial sounds

Answer 47

Bronchial = LOUD and higher in pitch; usually heard over the manubrium

Question 48

Normal breath sounds: Bronchovesicular

Answer 48

Bronchovesicular = INTERMEDIATE intensity and pitch; usually heard over the 1st and 2nd interspaces

Question 49

What are the three types of normal sounds when auscultating the lungs?

Answer 49

Vesicular sounds, bronchial sounds, and bronchovesicular sounds

Question 50

What are adventitious sounds?

Answer 50

Adventitious sounds = added sounds | Crackles, wheezes, and rhonchi

Question 51

What are three examples of adventitious sounds?

Answer 51

Crackles, wheezes, and rhonchi

Question 52

What is consolidation of the lungs?

Answer 52

Consolidation = increased tissue density due to being filled with blood, fluid, mucous

Question 53

What are the special tests for lungs when consolidation is suspected?

Answer 53

Egophony, bronchophony, whispered pectoriloquy, diaphragmatic excursion

Question 54

Special Test: Broncophony

Answer 54

Bronchophony “99” while auscultating, “normal” should sound muffled or indistinct If loud = (+) bronchophony

Question 55

Special Test: Egophony

Answer 55

Egophony Have patient say “EE” while auscultating “Normal” should sound like a muffled, long “E” sound If it sounds like “A”, then there is an E to A change = (+) egophany

Question 56

Special Test: Whispered Pectoriloquy

Answer 56

Whispered Pectoriloquy Have the patient whisper “99” as you auscultate Normally the “99” is faintly heard, indistinctly heard, or not heard at all If the “99” is louder and clearer = (+) whispered pectoriloquy

Question 57

Special test: Diaphragmatic Excursion

Answer 57

Diaphragmatic Excursion Movement of the diaphragm during breathing Percuss to find border of resonant to dull That is the diaphragm Mark this Have the patient inhale and hold breath Percuss from that mark until you find dullness again Normal 3-5 cm excursion

Question 58

Thorax Doc EX

Answer 58

Thorax is symmetric with good expansion. Lungs resonant. Bilateral breath sounds vesicular; no rales, wheezes, or rhonchi. Diaphragm descends 4cm bilaterally. Lungs CTA bilaterally. No crackles, wheezes or rhonchi bilaterally. Thorax symmetric with moderate kyphosis and increased anteroposterior (AP) diameter, decreased expansion. Lungs are hyperresonant. Breath sounds distant with delayed expiratory phase and scattered expiratory wheezes. Fremitus decreased; no bronchophony, egophony, or whispered pectoriloquy. Diaphragm descends 2 cm bilaterally.

Question 59

What does lung tissue lack?

Answer 59

Lung tissue itself has no pain fibers; pain in lung conditions usually arises from inflammation of the adjacent parietal pleura

Question 60

Pleural effusion

Answer 60

abnormal amount of fluid around the lung