OSCE 11 - Lower Resp. Exam - Nov. 17, 2015

Question 1

Lines we care about when inspecting chest

Answer 1

Anterior/posterior/ midaxillary line - ant. and pos. drop vertically from pos. axillary folds. Midaxillary from apex of the axilla
Midsternal line and midclavicular line - midsternal from the suprasternal notch. midclavicular form the midpoint of the clavicle

Question 2

sternal angle occurs where..

Answer 2

2nd rib meets w/ the manubrium and the body of sternum

Question 3

needle decompression landamrks

Answer 3

2nd intercostal space just superior to the 3rd rib margin (n.v. bundle is inferior to each rib) at midclavicular line for emergent decompression tension pneumothorax
-followed by chest tube placement

Question 4

chest tube insertion landmark

Answer 4

4th intercostal space at mid/ anterior axillary line in the 4th intercostal space just superior to the margin of the 5th rib

Question 5

T4 relevance

Answer 5

lower margin of endotracheal tube on chest x-ray

Question 6

7th intercostal space

Answer 6

landmark for thoracentesis

Question 7

evaluation of respiration (rate, rhythm, depth and effort)

Answer 7

healtht rat 14-20 / min
- note assymmetry, intercostal retractions
- cyanosis (hypoxia)
- breathing (audible wheezing etc.)
- pursed lips while breathing (obstructive lung dz.)
- patients with obstructive lung disorders tend to sit leaning forward with shoulder elevated
- neck inspection - contraction of accessory muscles (sternomastoid, scalenes or supraclavicular retraction)
tracheal position - should be midline (ex. lateral displacement of the trachea can occur in tension pneumothorax)

Question 8

fingernail clubbing description, mechanism

Answer 8

• bulbous swelling of soft tissue at nail base
• loss of normal angle between nail and proximal nail fold (>180 degrees) leading to spongy/ floating feeling
• mech. may involve vasodilation, changes in ct. tissue, innervation or PDGF form platelet clump fragments

Question 9

clubbing of fingernails indicative of

Answer 9

seen in congenital heart dz, interstitial lung dz, lung cancer, cystic fibrosis

Question 10

focus on these when palpating chest

Answer 10

- areas of tenderness
abnormalities in
- overlying skin
- resp. expansion
- tactile fremitus

Question 11

how do you check thoracic expansion?

Answer 11

place thumbs at level of 10th ribs

• fingers loosely grasping and parallel to the lateral rib cage
• patient inhales deeply
• watch thumbs as they move apart during inspiraiton, feel for range/ symmetry as rib cage expands and contracts

Question 12

how do you check tactile fremitus

Answer 12

• performed on ant. post. chest
• palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as patient speaks “ninety nine” or “one-one-one”
• follow pattern to right

Question 13

where is tactile fremitus most prominent?

Answer 13

• more prominent in the interscapular area than in the lower lung fields
• more prominent on the right than left
• disappears below diaphragm

Question 14

decreased/ absent fremitus indicates

Answer 14

COPD
pleural efusions
fibrosis
pneumothorax
infiltrating tumor

Question 15

increased fremitus indicates

Answer 15

pneumonia - increased transmission through consolidated tissue

Question 16

why do we percuss the chest?

Answer 16

to establish if underlying tissues are

• air filled
• fluid filled
• solid

Question 17

technique for percussing chest

Answer 17

• hyperextend middle finger and have only this finger firmly contact skin
• strike extended finger at DIP
• start superiorly percussing both sides of chest working toward base proceeding in a “ladder-like” pattern
• also done on anterior chest

Question 18

learn to identify these five percussion notes:

Answer 18

flat
dull
resonant
hyperresonant
tympanitic

Question 19

percussion and auscultation pattern for posterior thorax

Answer 19

• patient seated with both arms crossed in front of chest

- percuss/ ausc. thorax in symmetric locations

Question 20

generalized hyperresonance may be heard over hyperinflated lungs in

Answer 20

COPD

asthma

Question 21

unilateral hyperresonance suggests

Answer 21

• large pneumothorax

- large air-filled bulla in lung

Question 22

dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies space beneath percussing fingers and may indicate these pathologies

Answer 22

• lobaer pneumonia (alveoli filled w/ fluid and blood cells)
• pleural /accumulations:
  = Effusion (serous fluid)
  = hemothorax (blood) [treated w/ chest tube]
  = empyema (pus)
  = fibrous tissue/ tumor

Question 23

diaphragmatic excursion - how to check and normal

Answer 23

• determine distance between level of dullness on full expiration and level of dullness on full inspiration by progressive percussion down from resonance (lung parenchyma) to dullness (structures below diaphragm)
• normal excursion = 3 to 5.5 cm

Question 24

auscultation involves

Answer 24

listening to normal sounds generated by breathing

• listening for any adventitious (added) breath sounds
• if abnormality suspected ,listen to sounds of patients spoken or whispered voice

Question 25

normal breath sounds: vesicular

Answer 25

- soft and low pitched - heard through inspiration and about 1/3 of expiration - heard over most of lungs (parenchyma)

Question 26

normal breath sound: bronchovesicular

Answer 26

- intermediate in intensity and pitch - heard equally in inspiration and expiration - heard best in 1st and 2nd interspaces anteriorly and b/w the scapulae

Question 27

normal breath sound: bronchial

Answer 27

- loud and high pitched - exp. sounds heard longer than inspiratory - heard best over manubrium (larger proximal airways)

Question 28

normal breath sound: tracheal

Answer 28

- very loud and high pitched - heard equally in insp. and exp. - heard best over trachea in neck

Question 29

if bronchovesicular or bronchial breath sounds heard more distal to expected locations, suspect..

Answer 29

air-filled lung has been replaced by fluid-filled or solid lung tissue

Question 30

adventitious breath sounds

Answer 30

[superimposed on usual breath sounds] - crackles (rales) - wheezes and rhonchi - stridor - pleural friction rub

Question 31

crackles (rales)

Answer 31

discontinuous; intermittent, nonmusical and brief defined by: fine crackles: soft, high-pitched, very brief (5-10 msec) coarse crackles: louder, lower in pitch, brief (20-30 msec) - timing in resp. cycle insp., exp. or mid-insp./ exp.

Question 32

wheezes and rhonchi general description.

Answer 32

continuous; musical quality and prolonged (not necessarily the entire resp. cycle)

Question 33

wheezes description; indicates?

Answer 33

relatively high pitched, musical, hissing or shrill quality | - suggest narrowed airways (asthma, COPD, bronchitis)

Question 34

rhonchi description; indicates?

Answer 34

- relatively low-pitched, snoring quality | - suggest secretions in large airways

Question 35

stridor description

Answer 35

- wheeze that is entirely or predominantly inspiratory in nature - often louder in neck vs. chest wall - indicates partial obstruction of larynx or trachea (immediate attention needed)

Question 36

pleural friction rub description

Answer 36

- inflamed and roughened pleural surfaces grate against each other as they are momentarily and repeatedly delayed by increased friction - sounds like creaking, usually during exp. but can occur in both phases of respiration - usually confined to a relatively small area of chest wall

Question 37

if abnormally located bronchovesicular or bronchial breath sounds are heard (pneumonia, consolidations, effusions) you should..

Answer 37

assess transmitted voice sounds

Question 38

patient says "99" while doc listens to lungs; if abnormal, can have..

Answer 38

normally sounds transmitted through healthy lungs are muffled and indistinct. (can also palpate tactile fremitus while patient speaking) - BRONCHOPHANY: spoken words become louder and clear

Question 39

patient says "ee"; if abnormal can have..

Answer 39

normally should hear muffled long E sound - EGOPHANY: "ee" sounds like "a" - "A" has nasal bleating quality and should be localized

Question 40

in patients with fever and cough, the presence of bronchial breath sounds and egophony..

Answer 40

more than triples the likelihood of pneumonia!

Question 41

patient whispers "ninety-nine" or "one-two-three"; if abnormal, can have..

Answer 41

- normally a whispered voice is faint and indistinct or not heard at all - WHISPERED PECTORILOQUY: whispers are heard louder and clearer during auscultation