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Physical Assessment > Pulmonary > Flashcards

Flashcards in Pulmonary Deck (41):
1

HPI

SOB, cough/choking, sputum/characteristics, wheezing, hemoptysis, pleurodynia, chest/bacl pain, fever/night sweats, wt loss

2

Related Pulm Hx

PMH, PSH, Family Hx, Social Hx, Tobacco use/drugs/ETOH, environment, exposure

3

New Onset Dyspnea

PNA, PTHX, Pl Ef, Peanut/FB, P HTN, Peak seekers, PE, Pump porbs, Psychogenic, poisons

4

Health Promotion

smoking cessation- Inc CAm infertility, preterm birth, SID, low birth wt.

5 A's: Ask, Advise, Assess, Assist, Arrange

2 drugs to quit:

Nicotine replacement

Buprioprion- norepi/dopa reuptake inh/nicotine rec antagonist

Vareniche- nicotine receptor, partagonist

5

Plueral Effusion

Fluid displaces lung tissue away from costophrenic angle

6

Plueral Effusion

Fluid displaces lung tissue away from costophrenic angle

7

Thorax Anatomy

12 prs ribs

12 thoracic spine

suprasternal notch

manubrioangle

costal angle A/P

clavicular reference points

axillary reference points

Tip of scapula T7, if bent over most prominent cspine 7

8

Where to listen to which lobe

RUL- A/P

RML- A

RLL- P

LUL- A

LLL-P

9

Fissures

Minor: between right lobes

Major: between left lobes

10

Inspect Thorax

Rate, Rhythm, Depth, Effort

Listen to breathing

Shape/Symmetry

Neck/Trachea

AP diameter

Skin- clubbing, cyanosis(lips, nails)

Bony deformities

Retractions

11

Pectus Carinatum

Pigeon Chest

12

Pectus Excavatum

Funnel chest

13

Accessory Muscle Use

Muscles: Scalene, Trapezius, Sternomastoid

Retractions- caused by high work of breathing or airway blockage.

Check top of ribcage and ICS

Bulging between ribs may indicate PTX

Inward mvmt of soft tissue reflects -pressure during forced inspiration

 

14

Tracheal Position

Deviates to side of less pressure

Deviates toward atelectasis, fibrosis, simple PTX

Deviates away from Pl Eff, Tension PTX

15

Abnormal Breathing Patterns

Obstructive breathing

Ataxic breathing (Biots)

Cheyne-stokes breathing

Kussmaul breathing (deep fast or slow- blow off CO2 from acidosis)

Sighing Respirations

16

Inspection: Chest Symmetry

Equal movement bilaterally

One sided movement only?

Consider: hemidiaphragm paralysis, PTX, Old lung resection, fibrosis

17

Auscultation Technique

Sit up

Deep breathe through mouth

stethescope on skin

TV, Radio, Visitors OFF

Systematic comparision L/R and all lobes

18

Normal Breath Sounds

Bronchial

Pitch: high

Amplitude: loud

Duration: I

Quality: harsh or hollow

Normal location: trachea

found over high lung fields over fast moving air, mainstem bronchi, trachea

19

Normal Breath Sounds

Bronchovesicular

Pitch: medium

Amplitude: moderate

Duration: I=E

Quality: mixed

Normal location: over major bronchi

20

Normal Breath Sounds

Vesicular

Pitch: low

Amplitude: sofr

Duration I>E

Quality: soft blowing

Normal location: peripheral lung fields, posterior and lower areas

21

Adventitious Sounds Discontinuous

Fine Crackles/ Rales

fine crackles/rales

Mechansm: inspired air collides with deflated terminal airways

Early: COPD, Chronic Bronchitis

Late: PNA, CHF, Fibrosis, RLD

Deflated airways- fluid pressure(serum, mucus or inf materials) or mech restiction/comp; fine crackles are high pitched and heard on exp.

22

Adventitious Sounds Discontinuous

Course Crackles/ Rales

Mechanism: inspired air collides with fluid or secretions in bronchi

examples: P Edema, PNA, Bronchiectasis and Moribund patients

23

Adventitious Sounds Discontinuous

Atelectasis crackles/rales

Mechanism: when secretions of alveoli are not aerated (deflated)

Examples: bedridden, postop, depressed respirations

location: axillae, bases

clear/reversible on exam

Fine crackles from opening collapsed alveolar sacs- can resolve temporarily with CDB

24

Adventitious Sounds Discontinuous

Pleural Friction Rub

Mechanism: inflammed pleura cause friction during respiration

Example: Pleuritis, TB, malignancy, PE, PNA, viral syndromes( Influenza),

during inspiration

25

Adventitious Sounds Continuous

Wheeze (high pitched/rhonchi)

Mechanism: air flow through compressed/swollen airways

predominately in expiration

Examples; COPD, Asthma, tumors, CHF

26

Adventitous Sounds Continuous

Wheeze (low pitched/rhonchi)

Mechanism: airflow obstruction by secretions or bronchospasm

clears somewhat with cough/suctioning

 Bronchitis- major cause in outpts.

Sonorous, may be coarse as well as low cracles present

27

Adventitious Sounds

Mediastinal Crunch

Precordial crackles synchronous with heart beat

Mechanism: mediastinal emphysema (pneumomediastinum)

Examples: postop CV surgery, mech vent, PTX

procedure or pathology that introduces air to MS space

28

Tactile Fremitus

refers to palpable vibration when patient speask

used to check symmetry

"99" or " 1 1 1"

Increased or absent with lobar consolidation, pl eff and obstruction

reflects increased transference of voice through partially filled fluid lung. If + check bronchophony, egophony, and whispered petriloquy

29

Percussion

determines if underlying structure is air, fluid or solid

vibrates tissue and chest wall

symmetrical or generalized

best used to ID pl eff, empyema, PTX

normal: resonant

dull: consolidation (acculmulation pus, cellular debris with PNA)

flat: fluid filled (Pl Eff, some PTX, HTX)

30

Percussion Sounds

Flat

Dull

Resonant

Hyperresonant

Typmanic

Uses: Diaphragm excursion, Pl Eff, PTX

 

31

Alteration of Breath/Voice Sounds

Bronchial BS: loud/high pitched- lobar PNA

Egophony: EE to AY changes- with consolidation (PNA)

Bronchophony: louder/clear with consolidation (PNA)

Whispered Pectoriloquy: 1-2-3 whispered- sounds clear/loud with consolidation (PNA)

32

Lobar PNA

Percussion: dull

TF: increased

Bronchophony, Egophony, WP- present

Abn bronchial sounds

consolidation of infection (mucus, bacterial material, cellular debris)

33

Pleural Effusion

Percussion: dull to flat

TF: decr or absent

B, E, WP: may be present near top

BS- decreased

Fluid from inc Pl pressure from CHF transudative or inf/CA- exudative

Fill pl space between visceral(lung tissue) and parietal(chest wall), compressing lung parenchyma, lose BS at base often unilat.

34

Pneumothroax (PTX)

Percussion: hyperresonant

TF: dec or absent

B, E, WP: decr or absent

BS: absent

 Lung collapse(spont/iatrogenic); pleural space is partly air filled->compresses lung tissue- fluid filled space dull(effusion), air filled space hyperresonant

35

COPD

Percussion: hyperresonant

TF: decrea

B, E, WP- decreased

BS: decreased with prolonged expiration

Alveolar walls broken down, small air spaces become large with less surface area for gas exchange but more air trapping and decr exp flow= obstr disease

36

Atelectasis

Percussion: dull

TF: decr

B, E, WP: decr/absent

BS: decr/vesicular

Collapsed alveoli at bases- not air/fluid filled, but dull to percussion, no voice transfer

37

Clubbing of digits

Osteoarthopathy

Early: nail base spongy, angle close to 180 degrees

Late: nail base elevated or swollen, nail angle greater than 180 degrees

38

Pneumonia

Air space disease and consolidation. Space filled with bacteria or other microorganisms/pus

Other causes of air space filling not distinguishable radiographically would be fluid: inflammatory, cancer cells, protein (alveolar proteinosis), and blood (pulm hemmorghage).

PNA not associated with volume loss

CXR: air space opacity, lobar consolidation or interstitial opacities.

Masses are well defined

PNA may have associated parapneumonic effusion

39

PNA- CXR findings

Lobar: pneummococcal, entire lobe consolidation/ air bronchograms common

Lobular: Staphlococcus, multifocal, patchy, sometimes wo bronchograms

Intersititial: Viral/mycoplasma, latter starts perihilar and can become confluent and/or patchy as disease progresses, no air bronchograms

Aspiration PNA: follow gravity flow, imp consciousness, post anestesia, common with alcoholics, debilitated, demented, anerobic: bacterorides, fusobacrerium

Diffuse pulm inf: community acquired(mycoplasma), nosocomial(pseudomonas, debilitated, mech vents, high mortaltiy rate, patchy opacity, caviation, ill-defined nodular), immunocompromised host(bacterial, fungal, PCP)

40

Atelectasis vs PNA

Atelectasis: volume loss, assoc ipsilateral shift, linear wedge shaped, apex at hilum.

PNA: Normal/inc volume, no shift, or if present contralateral, consolidation, air space process, not centered at hilum

Air bronchograms can occur in both

41

Cough

acute < 3 weeks

subacute 3-8 weeks

chronic > 8 weeks