Lecture One (thorax+lungs)- Exam 2 Flashcards
1
Q
What are the different anatomic descriptors of the chest? (6) 🌟
A
- Supracalvicular: above the clavicles
- Infraclavicular: below the clavicles
- Interscapular: between the scapulae
- Infrascapular: below the scapulae
- Bases of the lungs: the lowermost portions
- Upper, middle and lower lung fields
2
Q
What are the different components of the health history for throax? (7)
A
- Common or concerning symptoms
- Chest pain
- Shortness of breath (dyspnea)
- Wheezing
- Cough
- Blood-streaked sputum (hemoptysis)
- Daytime sleepiness or snoring and disordered sleep
3
Q
Complaints of CP or chest discomfort raise concerns about what?
A
the heart but often arise from other structures in the thorax and lungs
4
Q
How do you assess the symptom of CP or chest discomfort?
A
To assess this symptom, you must pursue a dual investigation of both thoracic and cardiac causes.
5
Q
What are different sources of CP and causes? ⭐️
A
- The myocardium Angina pectoris, myocardial infarction, myocarditis
- The pericardium Pericarditis
- The aorta Aortic dissection (tearing pain to back)
- The trachea and large bronchi Bronchitis
- The parietal pleura Pericarditis, pneumonia, pneumothorax, pleural effusion, pulmonary embolus
- The chest wall, including the musculoskeletal and neurologic systems
- Costochondritis (infection between ribs), herpes zoster (along dermatome)
- The esophagus Gastroesophageal reflux disease, esophageal spasm, esophageal tear
- Extrathoracic structures such as the neck, gallbladder, and stomach Cervical arthritis, biliary colic (gallbladder pain can radiate to scapula), gastritis
6
Q
What should you ask the patient about their chest?
A
to point to the location of the pain in the chest
7
Q
- What does a clenched fist over the sternum suggest?
- What does a finger pointing to a tender spot on the chest wall suggest?
- What does a a hand moving from the neck to the epigastrium suggest?
A
- A clenched fist over the sternum suggests angina pectoris
- a finger pointing to a tender spot on the chest wall suggests musculoskeletal pain
- a hand moving from the neck to the epigastrium suggests heartburn.
8
Q
What should you make every effort to determine SOB and wheezing
A
Determine its severity based on the patient’s daily activities
9
Q
What are questions you can ask the patient to determine the severity of SOB/wheezing based on daily activities? (3)
What should you carefully elicit?
A
- How many steps or flights of stairs can the patient climb before pausing for breath?
- What about carrying bags of groceries, vacuuming, or making the bed?
- Has shortness of breath altered the patient’s lifestyle and daily activities? How?
- Carefully elicit the timing and setting, any associated symptoms, and relieving or aggravating factors
10
Q
What is the most common cause of acute cough? ⭐️
A
Viral UR infection
11
Q
What are other causes of acute cough?
A
Also consider acute bronchitis, pneumonia, left-sided heart failure, asthma, foreign body, smoking, and ace-inhibitor therapy
FLAP AAS
12
Q
What can cause subacute cough?
A
Post infectious cough, pertussis, acid reflux, bacterial sinusitis, and asthma
AAPP B-
13
Q
Where can chronic cough be seen in?
A
in postnasal drip, asthma, gastroesophageal reflux, chronic bronchitis, and bronchiectasis (in children)
14
Q
What should you ask about the coughing to your patient?
A
- Productive? (dry, sputm)
- Volume of sputum, color, odor and consistencty
* Purulent?
* Hemoptysis?
* Mudcoid (translucent, white or gray)
* Foul-smelling? (abscess or bacterial infection)
* Large volume of purulent sputum (bronchiectasis and lung abscess
15
Q
What are important topics for health promotion and counseling?
A
- Tobacco cessation (are you interested in stopping? education?)
- Lung cancer (when to do screening)
- Immunization: covid, influenza, pneumonia vaccines
16
Q
What is the initial survey of the chest?
A
- Observe the rate, rhythm, depth, and effort of breathing
17
Q
A healthy resting adult breathes quietly and regularly about _ times a minute.
A
20 (range of 16-20)
18
Q
What are the signs of respiratory distress (overview)?
A
19
Q
What signals hypoxia?
A
Cyanosis of lips, tongue, and oral muscosa
20
Q
What are you listening for with audible sounds of breathing?
A
- High-pitched inspiratory whistling, or stridor, is an ominous sign of upper airway obstruction.
- Wheezing is either expiratory or continuous
21
Q
What do you do for inspection of the neck?
A
- During inspiration, contraction of the accessory muscles (SCM and scalene) (COPD)
- Supraclavicular retraction?
- During expiration, contraction of the intercostal or abdominal oblique muscles
- Trachea midline (pneumothorax, pleural effusion, atelectasis)
22
Q
- When is pneumothorax common?
- Why do we care that the trachea is midline?
A
- Collaspe of lung common in tall males
- Trachea dev. towards the pneumothorax
23
Q
What is bradynea and some causes (4)?
A
Rate < 12/min: Bradypnea
* Metabolic alkalosis: volume depletion, vomiting
* Narcotics
* Raised intracranial pressure
* Extreme Obesity
24
Q
What is tachypnea and some causes of it (5)?
A
Rate > 20-25/min: Tachypnea
* Metabolic acidosis: DKA
* Hypoxemia
* Stimulants
* Anxiety
* Pain
25
What are signs of respiratory distress?
.
26
What is the tri-pod position?
In cases of real distress, pts may lean forward, resting their hands on their knees. In emphysema will purse their lips
| Common in COPD and lung cancer pts
27
What do we inspect of the chest?
* Observe shape of the chest
* Ratio of the anteroposterior (AP) diameter to lateral chest diameter is 0.7 up to 0.9 and increases with aging
* >0.9 in COPD, producing barrel-chest appearance
28
What should the anteroposterior diameter be? What is it in COPD?
* Ratio of the anteroposterior (AP) diameter to lateral chest
diameter is 0.7 up to 0.9 and increases with aging
* >0.9 in COPD, producing barrel-chest appearance
29
What is funnel chest (pectus excavatum)? What can it cause?
* Note depression in the lower portion of the sternum.
* Compression of the heart and great vessels may cause murmurs
30
What is this?
Pectus excavatum
31
What is barrel chest? Common in who?
* There is an increased AP diameter.
* This shape is normal during infancy, and often accompanies aging and chronic obstructive pulmonary disease.
32
What is this?
Barrel chest
33
What is Pigeon Chest (Pectus Carinatum)
* The sternum is displaced anteriorly, increasing the AP diameter.
* The costal cartilages adjacent to the protruding sternum are depressed.
34
What is Traumatic Flail Chest? What does it look like for respiration?
Multiple rib fractures may result in paradoxical movements of the thorax.
As descent of the diaphragm decreases intrathoracic pressure, on inspiration, the injured area caves inward; on expiration, it moves outward.
35
What do you do for palpation of the chest?
* Identify tender areas.
* Carefully palpate any area where the patient reports pain or has visible lesions or bruises.
* Tenderness, bruising, and bony “step-offs” are common over a fractured rib. Crepitus may be palpable in overt fractures and arthritic joints
36
Tenderness, bruising, and bony “step-offs” are common in what?
over a fractured rib
37
What can be palpable in overt fractures and arthritic joints?
Crepitus
38
How do you test chest expansion?
* Place your thumbs at about the level of the 10th ribs, with your fingers loosely grasping and parallel to the lateral rib cage.
* As you position your hands, slide them medially just enough to raise a loose fold of skin between your thumbs over the spine.
* Ask the patient to inhale deeply. **Watch the distance between your thumbs as they move apart during inspiration, and feel for the range and symmetry of the rib cage as it expands and contracts.**
* This movement is sometimes called lung excursion.
39
What do you watch for in test chest expansion?
Watch the distance between your thumbs as they move apart during inspiration, and feel for the range and symmetry of the rib cage as it expands and contracts.
40
* What is tactile fremitus?
* Where is Fremitus more prominent?
* Fremitus refers to the palpable vibrations that are transmitted through the bronchopulmonary tree to the chest wall as the patient is speaking normal.
* Fremitus is more prominent in the interscapular area than the lower lung fields.
41
What is indicative of fremitus is decreased or absent?
* voice is higher pitched or soft
* Impeded by a thick chest wall, an obstructed bronchus, COPD, pleural effusion, fibrosis, air (pneumothorax), or tumor
42
Tactile fremitus: What does it feel like
* Increased:
* Decreased:
* Increased: coarser or rougher
* Decreased: feels muffled or diminised
43
Occurs when sound vibrations travel through medium of abnormal density
* What does it mean when it is increased and decreased for tacile fremitus?
Increased
* Consolidation: Lobar pneumonia, tumor
* Heavy bronchial secretions
* Segmental atelectasis
Decreased
* Emphysema
* Pleural effusion, fibrosis or thickening
* Massive pulmonary edema
* Hemothorax (one sided)
44
What are some tactile fremitus tips we should know?
* Use either ball or ulnar surface of your hand
* Optimizes the vibratory sensitivity of the bones in your
hand
* Ask the patient to repeat the words “ninety-nine” (good vib word) or “one- one-one”
* Identify areas of increased, decreased, or absent fremitus
* If faint, ask pt to speak more loudly or in deeper voice
45
What are these for?
Auscultation
46
Percussion establishes what?
Establishes whether underlying tissues are
* Air-filled
* Fluid-filled
* consolidated
47
How deep does percussion go?
Penetrates 5-7 cm into chest; will not aid in detection of deep-seated lesions
48
How do you perform a percussion
* Hyperextend the middle finder of your left hand.
* Press its distal interphalangeal joint firmly on the surface to be percussed
* Avoid surface contact by any other part of the hand because it dampens out vibrations
* With a quick, sharp motion, strike the pleximeter finger with the right middle finger.
* Strike using the tip of the finger, not the finger pad.
49
What is the ladder pattern and what is it used for?
Percussion and auscultation
50
What are some tips for percussion?
* Have the patient keep both arms crossed in front of the chest
* Percuss one side of the chest and then the other in the ladder-like pattern.
* Omit areas over the scapulae
51
Fill in for percussion sounds
52
What do these percussion sounds mean:
* Resonant:
* Hyperresonant:
* Hyperresonant on one side:
* Dullness:
* Resonant = Normal
* Hyperresonant = hyperinflated. COPD, ASTHMA
* Hyperresonant on one side = pneumothorax
* Dullness = Fluid or solid
53
How do you auscultate?
* Listen directly on skin with the diaphragm of stethoscope
* Instruct patient to breathe deeply through an open mouth
* Use the ladder pattern
* Listen to at least one full breath in each location
* If patient becomes light-headed, allow patient to take a few normal breaths
54
Fill this in for breath sounds ⭐️
55
What are adventitious breath sounds?
* May be continuous
* Cont. long sounds are divided into **wheezes and rhonchi**
* Discontinuous lung sounds are called **crackles**
* **Stridor**: inspiratory and expiratory, harsh wheeze like accompanied by retractions
## Footnote
If a patient is sick, have them cough deep to hopefully clean up so there is no more rhonchi
56
For friction rub: what do you hear? (pitch, quality, and timing)
* Pitch: Low to medium
* Quality: Raspy, dry, scratchy (e.g. leather rubbing on leather)
* Timing: I, E, or both, usually loudest at end inspiration and early expiration; sound disappears with breath holding
57
What are causes of friction rub?
Pleural irriation and inflammation
## Footnote
Hypertrophy + CHF enlargment
58
When are special tests used?
These are follow-up tests utilized when abnormal breath sounds are present and are performed via auscultation.
59
* What is egophony?
* What is bronchophony?
* What is the whispered pectoriloquy?
| ⭐️
* **Egophony** – ask the patient to say “eeeee” then it should sound like a muffled long E. *If it sounds like an “A”, egophony is present and may indicate lung pathology*
* **Bronchophony** – ask the patient to say “ninety-nine”, should sound muffled, *if the sound is loud, may indicate lung pathology*
* **Whispered pectoriloquy** – ask the patient to whisper “ninety-nine”, should sound like a whisper, *if loud and clear, may indicate lung pathology*
60
Fill in
61
A 39-year-old architect comes to the clinic for a 2-day history of fever, chills, cough productive of green sputum, and dyspnea. He has no history of serious illness. His temperature is 101.2ºF. His other vital signs are within normal limits. Late inspiratory crackles are heard on auscultation over the left lower lung posteriorly. When the clinician listens over that area and instructs the patient to say “ee,” it sounds like “A.” Which of the following would most likely be found on percussion of his lungs?
1. Stridor
2. Dullness
3. Hyperresonance
4. Tympany
5. Flatness
2. Dulliness
REASON:
This patient has symptoms and signs of pneumonia. With pneumonia, a type of consolidation, dullness can be noted on percussion over the area of the pneumonia. Flatness is incorrect. Flatness is not noted on percussion over an area of pneumonia. Flatness is noted on percussion over muscles. Hyperresonance is incorrect. Hyperresonance is not noted
on percussion over an area of pneumonia. Stridor is incorrect. Stridor is a type of adventitial (added) lung sound, rather than a sound noted on percussion. Stridor is also not an adventitial lung sound heard in a patient with pneumonia. Tympany is incorrect. Tympany is not noted on
percussion over an area of pneumonia. Tympany is noted over percussion of the gastric air bubble.
62
After examining a patient who is in the hospital for shortness of breath, the clinician records the following for lung examination: “There is dullness to percussion over the right lung base. Breath sounds are absent at the right lung base. There are no crackles, wheezes, or rhonchi. There are no transmitted voice sounds.” Which of the following is the most likely diagnosis?
1. Pneumonia
2. Atelectasis
3. Chronic obstructive pulmonary disease (COPD)
4. Left-sided heart failure
5. Pneumothorax
2. Aterlectasis
63
A 13-year-old girl is brought by her mother to the clinic one day before the start of eighth grade because of a 3-day history of episodes of shortness of breath. When she gets the shortness of breath, she also notices tingling around her lips. She has no fever, cough, sputum production, or chest pain. She has no history of serious illness and takes no medications. Vital signs are within normal limits. Cardiac, lung, and extremity examinations show no abnormalities. Which of the following is the most likely diagnosis?
1. Left-sided heart failure
2. Asthma
3. Anxiety
4. Aspiration of a foreign body
5. Pneumonia
3. Anxiety
REASON:
Tingling around the lips can be a symptom of anxiety. The start of a new school year can be anxiety provoking for children. The normal lung examination is consistent with anxiety. Aspiration of a foreign body is incorrect. She does not have a cough. Putting a foreign body in her mouth and aspirating it would be unusual at her age. Asthma is
incorrect. Asthma is a possible cause of shortness of breath but is less likely in this girl because of the tingling around her lips and lack of cough or chest tightness, in addition to the lack of wheezing on examination. Left‐sided heart failure is incorrect. Left‐sided heart failure is uncommon in children. She also has no other symptoms of heart failure, such as orthopnea or paroxysmal nocturnal dyspnea. She
has no history of heart disease, high blood pressure, or other conditions that could put at an increased risk of heart disease. She also has no crackles on lung auscultation, which can be heard in left‐sided heart failure. Pneumonia is incorrect. Pneumonia is less likely than anxiety
because of the lack of other characteristic symptoms of pneumonia (fever, cough, sputum production, and chest pain) and the normal lung examination.
64
A 70-year-old patient has suspected chronic obstructive pulmonary disease. The clinician instructs the patient to take a deep breath in, and then with his mouth open, breathe out as fast and completely as he can. For what is the clinician checking?
1. Bronchophony
2. Tactile fremitus
3. Whispered pectoriloquy
4. Egophony
5. Forced expiratory time
5. Forced expiratory time
REASON:
Forced expiratory time is assessed by asking the patient to take a deep breath in and then breathing out as fast and fully as he can with his mouth open. Bronchophony is incorrect. Testing for bronchophony is done by listening with a stethoscope while the patient says "ninety‐ nine." Egophony is incorrect. Testing for egophony is done by listening
with the stethoscope while the patient says "ee." Tactile fremitus is incorrect. Testing for tactile fremitus is done by feeling for palpable vibrations on the chest wall while the patient says "ninety‐nine." Whispered pectoriloquy is incorrect. Testing for whispered pectoriloquy is done by listening with the stethoscope while the patient whispers
"nine‐nine."
65
A 16-year-old boy is brought to the Emergency Department (ED) after a motor vehicle accident for shortness of breath for 1 hour. A chest x-ray shows a rib fracture and a pneumothorax on the right side. The ED physician decides that a chest tube needs to be placed in the fourth intercostal space. How does he determine where the fourth intercostal space is?
1. He finds the angle of Louis and then moves laterally to the first rib. He walks down from there to the fourth intercostal space.
2. He finds the suprasternal notch and then moves his finger laterally to the third rib. The fourth intercostal space is just below the third rib.
3. He finds the clavicle. The second intercostal space is just below the clavicle. He then walks down to third rib, third intercostal space, fourth rib, and then the fourth intercostal space.
4. He finds the angle of Louis and then moves his finger laterally to the third rib. The fourth intercostal space is just below the third rib.
5. He finds the sternal angle and then moves his finger laterally to the second rib. He then walks down to the second intercostal space, third rib, third intercostal space, fourth rib and then the fourth intercostal space.
Number 5: He finds the sternal angle and then moves his finger laterally to the second rib. He then walks down to the second intercostal space, third rib, third intercostal space, fourth rib and then the fourth intercostal space.
| https://quizlet.com/195966978/8-the-point-flash-cards/ for REASON
66
A 14-year-old high school student comes to the clinic for a 3-month history of periodic dyspnea when playing basketball. It resolves shortly after resting. He has not had fever, chills, cough, sputum production, or chest pain. He has no history of serious illness. Based on the boy's history, asthma is suspected. Which of the following sounds heard on expiration during lung auscultation would be most suggestive of asthma?
1. Stridor
2. Pleural rub
3. Rhonchi
4. Mediastinal crunch
5. Wheezes
Wheezes
REASON: Wheezes are suggestive of narrowed airways, as in asthma, chronic obstructive pulmonary disease, or bronchitis. Mediastinal crunch is incorrect. A mediastinal crunch is suggestive of pneumomediastinum, not asthma. Pleural rub is incorrect. A pleural rub can be suggestive of a pleural effusion or a pneumothorax, not asthma. Rhonchi are incorrect. Rhonchi are suggestive of secretions in larger airways, not asthma. Stridor is incorrect. Stridor is suggestive of partial obstruction of the larynx or trachea, not asthma.
67
A 29-year-old waiter comes to the clinic for a 2-month history of a cough. When he lowers his gown so the clinician can listen to his lungs, the clinician notices a depression of the lower part of his sternum. Which of the following best describes the appearance of his chest?
1. Pigeon chest
2. Barrel chest
3. Flail chest
4. Thoracic kyphoscoliosis
5. Pectus excavatum
Pectus excavatum
REASON: Pectus excavatum is a congenital abnormality in which the inferior part of the sternum is displaced inward. Barrel chest is incorrect. In a barrel chest there is an increased anteroposterior diameter. A barrel chest
often accompanies chronic obstructive pulmonary disease. Flail chest is incorrect. The injured area of a flail chest moves inward with inspiration and moves outward with expiration. Pigeon chest is incorrect. Pigeon chest, also known as pectus carinatum, is a congenital abnormality in which the sternum is displaced anteriorly. Thoracic kyphoscoliosis is
incorrect. Thoracic kyphoscoliosis is characterized by abnormal spinal curvatures and vertebral rotation, which are visible posteriorly (rather than anteriorly).
68
A clinician is percussing the lungs of a patient with chronic obstructive pulmonary disease to see if they sound hyperresonant. Which of the following is an example of good technique for percussion?
1. Put the third and fourth fingers next to each other on the chest.
2. Strike using the finger pad of the fourth finger.
3. The proximal interphalangeal joint is the joint that is struck.
4. Strike using the tip of the third finger.
5. The wrist is kept still during percussion.
Strike using the tip of the third finger.
69
After examining a patient who is in the hospital for shortness of breath, the clinician records the following for lung examination: “There is dullness to percussion over the right lung base. Breath sounds are absent at the right lung base. There are no crackles, wheezes, or rhonchi. There are no transmitted voice sounds.” Which of the following is the most likely diagnosis?
1. Pneumonia
2. Chronic obstructive pulmonary disease (COPD)
3. Left-sided heart failure
4. Atelectasis
5. Pneumothorax
4. Atelectasis
70
A 16-year-old boy is brought to the Emergency Department (ED) after a motor vehicle accident for shortness of breath for 1 hour. A chest x-ray shows a rib fracture and a pneumothorax on the right side. The ED physician decides that a chest tube needs to be placed in the fourth intercostal space. How does he determine where the fourth intercostal space is?
A. He finds the angle of Louis and then moves his finger laterally to the third rib. The fourth intercostal space is just below the third rib.
B. He finds the angle of Louis and then moves laterally to the first rib. He walks down from there to the fourth intercostal space.
C. He finds the suprasternal notch and then moves his finger laterally to the third rib. The fourth intercostal space is just below the third rib.
D. He finds the sternal angle and then moves his finger laterally to the second rib. He then walks down to the second intercostal space, third rib, third intercostal space, fourth rib and then the fourth intercostal space.
E. He finds the clavicle. The second intercostal space is just below the clavicle. He then walks down to third rib, third intercostal space, fourth rib, and then the fourth intercostal space.
D. He finds the sternal angle and then moves his finger laterally to the second rib. He then walks down to the second intercostal space, third rib, third intercostal space, fourth rib and then the fourth intercostal space.
71
A 39-year-old architect comes to the clinic for a 2-day history of fever, chills, cough productive of green sputum, and dyspnea. He has no history of serious illness. His temperature is 101.2ºF. His other vital signs are within normal limits. Late inspiratory crackles are heard on auscultation over the left lower lung posteriorly. When the clinician listens over that area and instructs the patient to say "ee," it sounds like "A." Which of the following would most likely be found on percussion of his lungs?
A. Dullness
B. Hyperresonance
C. Stridor
D. Tympany
E. Flatness
A.dullness
72
A 70-year-old patient has suspected chronic obstructive pulmonary disease. The clinician instructs the patient to take a deep breath in, and then with his mouth open, breathe out as fast and completely as he can. For what is the clinician checking?
A. Whispered pectoriloquy
B. Egophony
C. Forced expiratory time
D. Bronchophony
E. Tactile fremitus
C. Forced expiratory time
73
A 14-year-old high school student comes to the clinic for a 3-month history of periodic dyspnea when playing basketball. It resolves shortly after resting. He has not had fever, chills, cough, sputum production, or chest pain. He has no history of serious illness. Based on the boy's history, asthma is suspected. Which of the following sounds heard on expiration during lung auscultation would be most suggestive of asthma?
A. Mediastinal crunch
B. Pleural rub
C. Stridor
D. Rhonchi
E. Wheezes
E. Wheezes
74
A 13-year-old girl is brought by her mother to the clinic one day before the start of eighth grade because of a 3-day history of episodes of shortness of breath. When she gets the shortness of breath, she also notices tingling around her lips. She has no fever, cough, sputum production, or chest pain. She has no history of serious illness and takes no medications. Vital signs are within normal limits. Cardiac, lung, and extremity examinations show no abnormalities. Which of the following is the most likely diagnosis?
A. Left-sided heart failure
B. Asthma
C. Anxiety
D. Aspiration of a foreign body
E. Pneumonia
C. Anxiety
75
A 29-year-old waiter comes to the clinic for a 2-month history of a cough. When he lowers his gown so the clinician can listen to his lungs, the clinician notices a depression of the lower part of his sternum. Which of the following best describes the appearance of his chest?
A. Flail chest
B. Pectus excavatum
C. Thoracic kyphoscoliosis
D. Pigeon chest
E. Barrel chest
B. Pectus excavatum
76
A student is practicing the performance of a lung examination on a classmate. Which of the following is the correct order for performing the components of the lung examination?
Inspection, palpation, percussion, and auscultation
77
A clinician is percussing the lungs of a patient with chronic obstructive pulmonary disease to see if they sound hyperresonant. Which of the following is an example of good technique for percussion?
Strike using the tip of the third finger.
78
