Module 4

Question 0

Chest pain assessment

Answer 0

Ask about discomfort or unpleasant feelings ask patient to point to location; describe quality, quantity or severity; the timing of the pain, the setting in which occurs, and exacerbating factors

Question 1

Health history for respiratory system

Answer 1

Ask about chest pain, shortness of breath, wheezing, cough, blood streaked sputum

Question 2

Shortness of breath

Answer 2

Ask about the difficulty breathing; the onset of symptoms; with or without exertion and if with how much exertion produces dyspnea; how many steps can the patient climb before having to pause for breath?

Question 3

Cough

Answer 3

Acute: last less than three weeks
subacute: 3 to 8 weeks
Chronic: more than eight weeks

Is the cough dry?
if it produces sputum how much, what color, Odor, consistency?

Hemoptysis: assess volume as well as other sputum attributes

Question 4

Examination of posterior chest

Answer 4

1) Sitting position with arms folded across chest
2) Inspection: shape & movement of chest; any deformities or asymmetry; any abnormal retractions or impaired respiratory movement on one or both sides
3) Palpation: Identify tender areas; assess any visible abnormalities; test chest expansion; feel for tactile fremitus; compare symmetric areas of the lungs
4) Percussion: when comparing two areas, use the same percussion technique in both areas; Learn to identify the percussion notes, healthy lung is normally resonant; Percussion one side of the chest and then the other at each level; Determine the extent of diaphragmatic excursion
5) Auscultation: Identify patterns of breath sounds;

Question 5

Examination of anterior chest

Answer 5

1) examine in the supine position
2) Inspect the shape and movement of the Chestwall; deformities, asymmetry or abnormal retraction
3) Palpation: Identify tender areas, assess abnormalities, assess chest expansion and tactile fremitus
4) Percussion
5) Auscultation

Question 6

Vesicular breath sounds

Answer 6

Soft and low pitched

Heard over most of both lungs

Heard through inspiration and continue without pause through expiration, fading away during expiration

Question 7

Bronchovesicular breath sounds

Answer 7

Inspiratory and expiratory sounds are about equal

Often heard in the first and second interspaces anteriorly and between the scapula

Question 8

Bronchial breath sounds

Answer 8

Louder, harsher and higher in pitch

Short silence between inspiratory and expiratory

With expiratory sound lasting longer than inspiratory

Heard over the manubrium (the larger proximal airways)

Question 9

Tracheal breath sounds

Answer 9

Very loud and harsh with a relatively high pitch

Inspiratory and expiratory sounds are about equal

Heard over the trachea and the neck

Question 10

Crackles (or Rales)

Answer 10

Discontinuous

Intermittent, nonmusical, and brief

Like dots in time

Fine crackles are soft, high-pitched, very brief (5-10 msec)

Course crackles are somewhat louder, lower in pitch, and brief (20-30 msec)

Question 11

Wheezes and rhonchi

Answer 11

Continuous

> 250 msec, musical, prolonged

Like dashes in time

Wheezes are relatively high-pitched with hissing or shrill quality

Rhonchi are relatively low pitched with snoring quality

Question 12

Funnel chest

Answer 12

Depression the lower portion of the sternum

compression of the heart and great vessels may cause murmurs

Question 13

Barrel chest

Answer 13

Increased anterioposterior diameter

normal during infancy, often accompanies aging and chronic obstructive pulmonary disease

Question 14

Pigeon chest

Answer 14

Sternum is displaced anteriorly, increasing the anteroposterior diameter

costal cartilages adjacent to the protruding sternum are depressed

Question 15

Traumatic flail chest

Answer 15

Multiple rib fractures may result in paradoxical movements of the thorax

On inspiration the injured area caves inward on expiration it moves outward

Question 16

Thoracic kyphoscoliosis

Answer 16

Abnormal spinal curvatures and vertebral rotation deform the chest

Distortion of underlying lungs may make interpretation of lung findings very difficult

Question 17

Tripod position

Answer 17

Patient leans forward and rest the hands on the knees in order to open up airways to make breathing easier usually found in chronic lung diseases like COPD and emphysema

Question 18

Bronchophony

Answer 18

Spoken words are louder

Question 19

Epiphany

Answer 19

“ee” heard as “ay”

Question 20

Whispered pectoriloquy

Answer 20

Whispered words louder and clearer

Question 21

Stridor

Answer 21

Wheeze that is entirely or predominantly inspiratory

Indicates a partial obstruction of the larynx or trachea and demands immediate attention

Question 22

Pleural rub

Answer 22

Inflamed and roughened pleural surfaces grate against each other

Produce creaking sounds usually during expiration

Question 23

Mediastinal crunch

Answer 23

Series of precordial crackles synchronous with the heartbeat not with respiration

Question 24

Tactile fremitus

Answer 24

Palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as the patient is speaking Decreased: pleural effusion, pneumothorax, COPD, asthma, high pitched, very soft Increased: Consolidation, Towards the top of a large effusion

Question 25

Atelectasis (Lobar obstruction)

Answer 25

When a plug in the mainstem bronchus (mucous, foreign object) obstructs airflow Percussion: dull Trachea may be shifted toward involved side Breath sounds usually absent when the bronchial plug persists

Question 26

Emphysema

Answer 26

A type of COPD - Progressive disorder in which the distal airspace is enlarged and lungs become hyperinflated often associated with chronic bronchitis Percussion: Diffusely hyperresonant Trachea is midline Breath sounds are decreased to absent Decreased tactile fremitus

Question 27

Asthma

Answer 27

Widespread narrowing of the tracheobronchial tree diminishing airflow to a fluctuating degree. During attacks airflow decreases further and lungs hyperinflation. Percussion: resonant Trachea: midline Breath sounds: often obscured by wheezes Tactile fremitus: decreased

Question 28

Plural effusion

Answer 28

Fluid accumulation in the pleural space Percussion: dull to flat Trachea: shifted toward opposite side in large effusion Breath sounds: decreased to absent;$ possible pleural rub Tactile fremitus: decreased - absent; may be increased toward the top of large effusion

Question 29

Heart failure

Answer 29

Increased pressure in the pulmonary veins causes congestion and interstitial edema Percussion: resonant Trachea: midline Breath sounds: normal (vesicular); late inspiratory crackles in the dependent portions of the lungs; possible wheezes Tactile fremitus: normal

Question 30

Pneumothorax

Answer 30

Air leaks into the plural space, usually unilaterally, lung recoils from the chest wall Percussion: hyperresonant Or tympanic Trachea: shifted toward opposite side if much air Breast sounds: decreased - absent over the plural air; Possible pleural rub Tactile fremitus: decreased to absent

Question 31

Cardiac health history

Answer 31

Any chest pain, palpitations, shortness of breath (dyspnea, orthopnea, paroxysmal nocturnal dyspnea) swelling or edema.

Question 32

Basic cardiac exam

Answer 32

Blood pressure and heart rate Chest wall anatomy Jugular venous pulse, carotid upstroke, presence or absence of carotid bruits Identify and describe point of maximal impulse Correctly identify S1 and S2 at the base and Apex Evaluate murmurs Evaluate pulsus paradoxus

Question 33

S1 & S2

Answer 33

Closure of the mitral valve produces the first heart sound S1 Aortic valve closure produces the second heart sound S2

Question 34

Bruit

Answer 34

A murmur like sound arising from turbulent arterial bloodflow Usually caused by atherosclerotic narrowing of the internal carotid artery

Question 35

Heave / lift

Answer 35

Noted with palpation Lifts and heaves are sustained impulses usually produced by an enlarged right or left ventricle or atrium; occasionally by ventricular aneurysm