Thorax and Lungs Ch. 19

Question 1

What is the sternal angle and what is its signifcants?

Answer 1

It is a useful place to start counting ribs as it is continuous with the 2nd rib. Palpate the sternal angle, and slide down to the 2nd intercostal. Each intercostal space is numbered by the rib above it.
This is also where the trachea bifurcates

Question 2

What is the coastal angel

what is the costoverterberal (CVA)

Answer 2

• the angel under the anterior ribs, should be 90 degrees (>90 = barrel chest)
• where the ribs meet the spine, location of fist percussion

Question 3

what is the supra aspect of teh lungs called

Answer 3

apices

Question 4

describe the lobes of the right and left lung

Answer 4

right: 3 lobes, RML is at the 4th and 5th ICS
left: 2 lobes
apices are above the clavical, anterior LL end at the 6th ICS, posterior LL end at teh 9th ICS

Question 5

Important health history questions for respiratory (12)

Answer 5

Coungh (productive, dry), SOB, allergies (asthma), past lung injury, URIs, current meds (PMH), O2 at home, last TB sink test/ X-ray, PNA vaccine (>65, or immuno comp), flu vaccine, family history (CF, asthma), smoking (present/ past, pacs/ yr), chindren exposure to 2nd/ 3rd hand smoke?

Question 6

5 A’s to help smokers quit

Answer 6

1) Ask- about his or her tobacco use status at every visit
2) Advise- Give clear, nonjudgmental, and personalized suggestions for quitting
3) Assess- each person’s readiness for and interest in quitting
4) Assist- each person with a specific cessation plan that includes medications, behavioral modification, exercise programs, or referrals
5) Arrange- follow-up visits

Question 7

Problem based question to ask regarding a cough (3)

Answer 7

OPQRSTU
Constant, or does it come and go? Associated with specific activities, positions, or other symptoms i.e. fever?Describe your cough (Dry, Congested, Wet, Barking, Hacking)
Are you coughing up sputum

Question 8

What questions are asked about sputem and what it means

Answer 8

What is color of sputum: 
clear= vital
white
green= bacterial
bloody= ulcer

Consistency of sputum:
thick, thin, frothy (PE, heart failure, ARDS)

Does it have an odor? yes= bacterial

Question 9

what is bloody sputem called

Answer 9

hemoptysis

Question 10

Problem based question to ask regarding SOB (4)

Answer 10

OPQRSTU
How many stairs or blocks can you walk before you become SOB?
Does it wake you up at night? (Paroxysmal nocturnal dyspnea), How many pillows do you use? (orthopnea)
Does anything seem to trigger episodes or make it worse?
What do you do to relieve symptoms?

Question 11

Inability to breath when lying down:

Answer 11

orthopnea

Question 12

An attack of severe shortness of breath and coughing that generally occurs at night

Answer 12

Paroxysmal nocturnal dyspnea

Question 13

Pleuritis
what it is
s/s

Answer 13

(inflammation of pleura) = Pleural friction rub
can hear the rub with breathing. Can also occure in the heart; have the pt. hold theit breath while ascultating, sound will stop if it is the lungs and continue if it is the heart.
severe angina

Question 14

Chostochondritis
what it is
s/s

Answer 14

Inflammation of the cartilage that connects a rib to the sternum. Pain might mimic that of a heart attack

Question 15

physical exam: inspection of overall appearence (3)

Answer 15

1) General appearance (LOC may mean acute hypoxia), posture (tripoding, not wanting to lay down), breathing effort (symmetry in chest expansion, pursed liped breathing, nostral flaring)
2) Quality of respirations (rate, pattern, effort)
3) Nails, skin, lips (cyanosis, pallor)

Question 16

Quality of respirations (3)

Answer 16

Rate (older adult breathes after, babies may breath irregular)
Breathing pattern
Effort (SOB, retractions, accessory muscles)

Question 17

Breating patterns:
Cheyne Stoke
Tachypnea
Kussmaul
Hypoventilation
Bradypnea

Answer 17

1) Cheyne Stoke: tachypnea followed by apnea
2) Tachypnea: fast and shallow breaths (anything that causes SOB)
3) Kussmaul respirations= Hyperventilation: anxiety, DKA (diabetic ketoacidosis)
4) Hypoventilation: shallow slow irregular breaths (sedative (opioid) overdose, abd pain)
5) Bradypnea: slow breathing (least common), late sign of increased ICP

Question 18

Physical exam: Anterior chest and posterior thorax

Answer 18

IPPA for both

Question 19

Physical exam: Anterior chest INSPECTION (7)

Answer 19

Symmetry, Retractions, Accessory muscle use, Muscle development, Lesions, Anteroposterior (AP) diameter, Costal angle

Question 20

What is the Anteroposterior (AP) diameter
what is it compared to
how is it documented
what can it be a sign of

Answer 20

measurement from anterior to posterior. AP should be > transvers
(documented: AP>T, 1:2)
If AP=T could be a sign of barrel chest (which is a sign of COPD)

Question 21

What can asymmetry of the chest mean?

Answer 21

PNA, pneumonthorax, plural effusion

Question 22

Physical exam: Anterior chest PALPATION

Answer 22

Symmetric chest expansion
Tenderness, lumps, masses?
Skin temp, moisture
Crepitus 
Tactile Fremitus

Question 23

What can Crepitus signify?

Answer 23

= subcutaneous emphysema, feels like how rice crispy cereal sounds

Question 24

Tactile Fremitus palpation
how to palpate
how to assess what you feel
where are vibrations the strongest

Answer 24

Use ball of fingers or ulnar edge of hand to feel for vibrations, while patient says “99” or “blue moon”. Using both hands start on top of shoulders, and then palpate at 3 locations down the midclavicular line, ending at the 6th ICS (where the lung ends)

Assess bilaterally; symmetry is most important (asymmetry could mean consolidation, PNA)

Vibrations stronger around sternum where major bronchi are closest to chest wall

Question 25

How does consolidation effect breath sounds

Answer 25

Consolidation enhances the transmission of breath and voice sounds!!

Question 26

what is Rhonchal Fremitus

Answer 26

palpable vibrations with inhalation (may be caused by mucous in brachioli)

Question 27

Physical exam: Anterior chest PERCUSSION and ASCULTATION | how to percuss/ ascultate

Answer 27

start at the supraclavicular moving in a digital 2, and then palpate at 4 locations down the midclavicular line the 5th is closer to the axillary line, ending at the 6th ICS (where the lung ends).

Question 28

how to assess what you hear during percussion

Answer 28

Resonance is the normal finding. Hyperresonance= decreased density and increased air (eg: emphasema). Dullness= organs or fluid.

Question 29

how to assess what you hear during ascultation

Answer 29

Broncheal (tracheal) Loud, hollow Inspiration < Expiration Bronchovesicular (midsternal line) Moderate amplitude Inspiration = Expiration Vesicular (between ICS: supreclavicular to 6th ICS) Soft, rustling Inspiration > Expiration Regardless of the type of normal breath sounds you hear, we report and document normal lung sounds as “CLEAR” (no adventitious sounds)

Question 30

what can Broncheal in the LL mean (think about it!!)

Answer 30

PNA, b/c Consolidation enhances the transmission of breath and voice sounds!!

Question 31

PNA what it is what causes it Clinical findings:

Answer 31

pneumonia an infection that inflames the air sacs in one or both lungs. The air sacs may fill with fluid or pus (purulent material), causing cough with phlegm or pus, fever, chills, and difficulty breathing. A variety of organisms, including bacteria, viruses and fungi, can cause pneumonia clinical findings: tachypnea, asymmetric chest expansions, fever, elevated vitals, increased fremitus at LL, coarse crackles.

Question 32

physical exam: posterior thorax (IPPA)

Answer 32

Inspect: symmetry, shape (kyphosis or scoliosis limiting thoracic excursion?), skin Palpate: chest expansion, tactile fremitus (avoid scapula bones and spine... vibrations will be strongest between scapula) Percuss: same areas you palpated for fremitus. Should hear resonance! Auscultate: should hear vesicular, clear lung sounds Lungs extend to the 9th ICS

Question 33

what are the 6 adventitious breath sounds

Answer 33

1) Coarse crackles (rales) 2) Fine crackles (rales) 3) Pleural friction rub 4) Wheeze (high-pitched) 5) Wheeze (low-pitched) 6) Stridor

Question 34

Coarse crackles (rales):

Answer 34

Low-pitched bubbling sounds; heard on inspiration and/or expiration; may decrease with cough/suctioning. Could mean mucous, PNA, pulm fibrosis, chronic bronchitis. upperairway.

Question 35

Fine crackles (rales):

Answer 35

High-pitched crackling, popping sounds upon inspiration. Could mean Pulm edema (HF), PNA, chronic bronchitis. Fluid filled alvioli.

Question 36

Pleural friction rub:

Answer 36

Grating, low-pitched (like walking on snow). Could mean pleuritis.

Question 37

Wheeze (high-pitched):

Answer 37

High-pitched, musical, squeaking; usually expiratory. Could mean Airway obstruction from tumor, asthma, emphysema.

Question 38

Wheeze (low-pitched):

Answer 38

AKA rhonchi; Snoring, moaning sounds. Could mean Bronchitis (upper airway).

Question 39

Stridor:

Answer 39

EMERGENCY: High-pitched crowing sound; louder in neck. Could mean croup, obstructed airway.

Question 40

physical exam: infants and children (4)

Answer 40

- Obligate nose breathers until 3 months - Newborn RR 30-40 bpm and may be irregular; count for full minute - AP diameter of 1:1 is a normal finding in individuals <6yo - Thin chest walls may cause you to hear louder bronchovesicular breath sounds throughout the lung fields; Percussion may yield hyperresonance

Question 41

Developmental Competence: Pregnancy (4)

Answer 41

- Enlarging uterus elevates diaphragm which decreases vertical diameter of the thorax; compensates by widening horizontally - Increase in tidal volume (TV) to meet increased oxygen demand (deeper respirations) - Wider costal angle - Some report mild dyspnea

Question 42

Developmental Competence: older adult (3)

Answer 42

- Costal cartilages become calcified, and lungs are more rigid causing lung bases become less ventilated and alveoli become closed off and thus less surface area is available for gas exchange and increased risk of postoperative pulmonary complications (atelectasis and infections) - Kyphosismay make thoracic expansion more difficult. - Older people fatigue more quickly during auscultation.

Question 43

Atelectasis what it is Clinical findings risk

Answer 43

collapsed alveoli (may be one section or entire lung); caused by external pressure from tumor, fluid, or foreign body. Most common post opp. complication. Clinical findings: Affected lobe has diminished or absent breath sounds. Oxygen saturation may be low. Decreased fremitus. Dullness with percussion. Can turn into PNA

Question 44

Chronic Bronchitis what it is cause Clinical findings

Answer 44

AKA smokers cough. Characterized by hypersecretion of mucus by goblet cells of trachea and bronchi resulting in productive cough. Caused by irritants such as cigarette smoke and air pollution or by infection. Clinical findings: Productive cough, increased mucus production (green mucous= bacterial infection on top of the bronchitis), and dyspnea. When mucus occludes alveoli, coars crackles or wheeze (low pitch) may also be heard.

Question 45

Emphysema what it is cause Clinical findings

Answer 45

destruction of pulmonary connective tissue that causes permanent abnormal enlargement of air spaces (hyper-inflated lung). Cause: long-term exposure to irritants that damage your lungs and the airways (smoking) Clinical findings: Classic appearance: underweight with barrel chest and SOB. Exam findings: diminished breath and voice sounds;possible wheezing on auscultation; decreased tactile fremitus; hyperresonant tones on percussion

Question 46

Asthma/ RAD what it is Clinical findings

Answer 46

RAD= Reactive Airway Disease Hyperreactive airway disease characterized bybronchoconstriction, airway obstruction, and inflammation. Clinical findings: Tachypnea with prolonged expiration. Audible wheeze. Dyspnea; Anxiety; Cough. Use of accessory muscles. Auscultation: wheezy and diminished

Question 47

COPD

Answer 47

Chronic Obstructive Pulmonary Disease. | chronic emphasema and bronchitis

Question 48

Pleural Effusion what it is Clinical findings

Answer 48

accumulation of serous fluid in pleural space (outside of the lung) Clinical findings: If large, there may be dyspnea or decreased chest wall movement. Decreased tactile fremitus. Percussion: dull (over fluid). Decreased breath sounds

Question 49

PE what it is Clinical findings

Answer 49

Pulmonary Edema fluid inside of the lung caused by a heart condition (back flow from the left heart). Other causes include PNA.

Question 50

Pneumothorax what it is Clinical findings

Answer 50

Partial or complete lung collapse resulting from air in pleural spaces. Clinical findings vary, depending on amount of lung collapse. Pt may be slightly SOB, anxious or in severe distress. Decreased chest wall movement Hyper-resonance on percussion. Breath sounds decrease or absent on affected side. Tracheal displacement

Question 51

TB what it is cause Clinical findings

Answer 51

tuberculosis: contagious (airbourn), bacterial infection caused by Mycobacterium tuberculosis. Primarily in lungs, but kidney, bone, lymph node, and meninges can also be involved. Clinical Findings: usually asymptomatic early on. May develop fatigue, anorexia, weight loss, fever, night sweats, crackles in apices, and cough (possible blood tinged/rust sputum)

Question 52

Lung cancer cause Clinical findings

Answer 52

Most fatal of all cancers: 85% caused by tobacco smoking Clinical findings: Most common initial symptom reported is a persistent cough. Weight loss, hemoptysis,SOB, Nail clubbing. If tumor is causing partial obstruction can cause atelectasis or wheezing. Percussion may be dull over a large tumor.

Question 53

ARDS what it is cause Clinical findings

Answer 53

Acute Respirtory Distress Syndrome a type of respiratory failure characterized by rapid onset of widespread inflammation in the lungs. High mortality. results from trauma or shock (but most often sepsis) leading to increased permeability of pulmonary capillaries. Leads to pulmonary edema. Clinical findings: Restlessness, dyspnea, Ventilatory support often required; suctioning will reveal frothy sputum

Question 54

What are the possible causes: | Upon inspection on the pt. you notice unequal chest expansion:

Answer 54

severe atelectasis, PNA, effusion, pneumothorax, trauma

Question 55

What are the possible causes: | Upon inspection on the pt. you notice they have a barrel chest, pursed lip breathing and hypertrophied muscles

Answer 55

COPD, emphysema

Question 56

What are the possible causes: | Upon palpation of the pt. you notice increased fremitus

Answer 56

consolidation due to PNA

Question 57

What are the possible causes: | Upon palpation of the pt. you notice decreased fremitus

Answer 57

obstruction, effusion, pneumothorax, emphysema

Question 58

What are the possible causes: | Upon palpation of the pt. you notice crepitus

Answer 58

subcutaneous emphysema

Question 59

What are the possible causes: | Upon percussion of the pt. you notice dullness

Answer 59

increased density of the lungs- PNA, effusion, atelectasis, tumor

Question 60

What are the possible causes: | Upon percussion of the pt. you notice hyperresonance

Answer 60

increased air- pneumothorax, emphysema

Question 61

What are the possible causes: | Upon ascultation of the pt. you hear crackles

Answer 61

PNA, bronchitis, pulm fibrosis, pulm edema (ARDS)

Question 62

What are the possible causes: | Upon ascultation of the pt. you hear wheezes

Answer 62

asthma, emphysema

Question 63

What are the possible causes: | Upon ascultation of the pt. you hear stridor

Answer 63

epiglottitis, croup

Question 64

What are the possible causes: | Upon ascultation of the pt. you hear plural effusion rub

Answer 64

pleuritis

Question 65

Hypercapnia

Answer 65

increased CO2 in the blood

Question 66

Egophony how is the test done normal abnormal

Answer 66

(Greek: “the voice of a goat”) Auscultate the chest while the person phonates a long “ee-ee-ee-ee” sound Normally you should hear “eeeeeeee” through your stethoscope Over area of consolidation or compression the spoken “eeee” sound changes to a bleating long “aaaaa” sound

Question 67

Bronchophony how is the test done normal abnormal

Answer 67

Ask the person to repeat “ninety-nine” while you listen with the stethoscope over the chest wall; listen especially if you suspect pathology Normal voice transmission is soft, muffled, and indistinct; you can hear sound through the stethoscope but cannot distinguish exactly what is being said Pathology that increases lung density enhances transmission of voice sounds; you auscultate a clear “ninety-nine” The words are more distinct than normal and sound close to your ear

Question 68

Whispered Pectoriloquy how is the test done normal abnormal

Answer 68

Ask the person to whisper a phrase such as “one-two-three” as you auscultate The normal response is faint, muffled, and almost inaudible With only small amounts of consolidation, the whispered voice is transmitted very clearly and distinctly, although still somewhat faint; it sounds as if the person is whispering right into your stethoscope, “one-two-three”