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PA: Exam 1 > 4. SESSION 4.3: Thorax & Breast > Flashcards

4. SESSION 4.3: Thorax & Breast Flashcards

0
Q

Four components of the anterior thoracic cage

A
  • Suprasternal notch
  • Sternum
  • Manubriosternal angle
  • Costal angle
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1
Q

Four components of the anterior thoracic cage

A
  • Suprasternal notch
  • Sternum
  • Manubriosternal angle
  • Costal angle (Less than 90 degrees. Greater than 90 degrees would be barrel chested. Under xiphoid process.)
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2
Q

Body has ___ pairs of ribs.

Body has ___ thoracic vertebrae.

A

12, 12

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3
Q

Name the three components of the sternum.

A
  • Manubrium (top part)
  • Body (middle)
  • Xiphoid process (tiny bone at bottom)
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4
Q

First ___ pairs of ribs connect to the ___ with ______.

Ribs ___ & ___ are free-floating.

A

First 7 pairs of ribs connect with the STERNUM with COSTAL CARTILAGE.
Ribs 11&12 are free-flowing.

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5
Q

The tip of the scapulae come down around ____ (what vertebra?)

A

T8

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6
Q

What landmark is at C7?

A

Vertebra prominens – a little spinous process

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7
Q

What landmark is at 12th rib?

A

Palpate midway between spine and side to find the location free tip.

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8
Q

Anterior reference lines (3):

A
  • Midline: “Midsternal line”
  • “Midclavicular line” - At midpoint of clavicle (closer to armpit than to midline)
  • In line with armpit: “Anterior axillary line”
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9
Q

Posterior reference lines (3):

A
  • “Vertebral line” (middle of spine)
  • “Scapular line” (midway between vertebral and axillary)
  • “Posterior axillary line”
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10
Q
  • What is the media steinum?

- What four components are included?

A

“The heart and the great vessels that lie between the lungs on either side”

  • The heart
  • The trachea
  • The esophagus
  • The great vessels
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11
Q

Lateral reference lines (3)

A
  • “Posterior axillary line”
  • “Mid-axillary line”
  • “Anterior axillary line”
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12
Q

Right pleural cavity holds _____

Left pleural cavity holds ______

A

The right lung, the left lung.

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13
Q

How many lobes on the left lung?
How many lobes on the left side?
Which lung is shorter and why?

A
  • Left lung = 2 lobes
  • Right lung = 3 lobes
  • Right lung is shorter because of the liver underneath.
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14
Q

Which lobe does a lot of nurses forget about? Why is this important?

A

Right middle lobe. This is the lowest draining spot of the right lung, so it is actually at a higher risk for infection or pneumonia.

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15
Q

The apex of the lung is _________

A
  • About 3cm above the clavicle
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16
Q

Costa diaphragmatic recess

  • Where is it?
  • What is a problem that can happen here?
A
  • A 3cm space below the lungs

- Pleural effusion - Too much fluid due to cancer or an infection

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17
Q

What is the pleura?

  • Name the two types
  • Why is this important?
A

Thin, slippery lining that forms an envelope around the lungs and the chest wall.

  • Visceral pleura lines lungs themselves
  • Parietal pleura lines inside of chest wall.
  • Small amount of fluid to allow for movement.
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18
Q

Difference in R & L bronchi:

A
  • Right main-stem bronchus is a little wider, shorter and staighter than left.
  • Left has sort of an angle. It’s harder to aspirate things into the left side of the lung.
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19
Q

Where does the biforcation of the bronchi into right and left occur?

A

At the angle of louis

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20
Q

____ pressure occurs upon inhalation
____ pressure occurs upon exhalation
**what happens to the diaphragm?

A

NEGATIVE upon inhalation (forces air in, diaphragm contracts).
POSITIVE upon exhalation (forces air out, diaphragm relaxes and domes).

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21
Q

1) Morning cough is due to ________
2) Afternoon cough is due to ________
3) Congestive or hacking cough is due to ______ or ______
4) Dry cough is usually _________

A

1) Smoking
2) Irritant
3) Bronchitis or pneumonia
4) Cardiac-related

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22
Q

Costocondritis

  • What is it?
  • What happens?
A
  • Inflammatory or rheumatic problem:

- CT between ribs and sternum becomes painful to the touch.

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23
Q

Subjective Data- Health History Questions

Seven things to ask about for the LUNG (7)

A

1) Cough
2) Dyspnea
3) Orthopnea
4) Chest pain with breathing
5) Hemoptysis
5) Past history of respiratory infections
6) Smoking history
7) Environmental exposure

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24
Q

What is dyspnea? (2)

A
  • Shortness of breath

- Coughing more than every 12 words

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25
Q

What is orthopnea?

  • What is it?
  • How do you ask about it?
A
  • Increased dyspnea while laying down.

- “How many pillows do you need to breathe comfortably at night?”

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26
Q

What happens if there is not enough fluid between the pleura?

A

Chest pain

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28
Q
  • What is the word for coughing up blood?

- What two things will cause this?

A

HEMOPTYSIS

  • Heart failure
  • Pulmonary embolus
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29
Q

Six elements of pulmonary physical assessment

A

1) Inspection
2) Respiratory excursion
3) Palpate for tactile fremitus
4) Percuss for symmetry
5) Diaphragmatic excursion
6) Auscultate posterior chest

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30
Q

How do you identify a barrel chest? (2)

A
  • Back to side ratio is less than 2:1 (Barrel chest is more like a 1:1 ratio)
  • Costal angle is less than 90 degrees
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31
Q

What is “normal” respiration?

- 4 things to look for

A
  • Facial expression indicates no discomfort
  • Regular, even
  • 10-20 breaths per minute
  • Skin color consistent with ethnic background
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32
Q

_________is when the sternum dips in closer to heart (two causes)

A

Pectus excavatum

- usually due to long term smoking, chronic bronchitis.

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32
Q

Two facial expressions to look for with chronic obstructive pulmonary disease.

(1) Facial expression 1:
- Caused by what?
- 3 characteristics
(2) - Facial expression 2:
- Caused by what? (2)
- 3 characteristics

A
  • “pink puffer” - severe emphysemia.
    Significant dyspnea, thin, uses intercostal muscles.
  • “blue bloater” - was a chronic smoker, now has chronic bronchitis.
    Air trapped in lungs, cyanosis, right heart failure.
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33
Q

Chronic obstructive pulmonary disease is associated with what two diseases?

A
  • Chronic bronchitis

- Emphysema

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34
Q

Tachypnea

  • Definition
  • 3 causes
A
  • Breathing faster than 24 respirations per minute

- Fever, pneumonia, exercise

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35
Q

Kussmaul

  • Definition
  • One cause
A
  • Looks normal, but breaths are much deeper, labored

- Seen in diabetics with acidosis (trying to breathe off their CO2)

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36
Q

Bradypnea

  • Define
  • 2 causes
A
  • Less than ten respirations per minutet
  • Certain drugs
  • Increased ICP
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37
Q

Cheyne-Stokes

  • Definition
  • 3 causes
A
  • Breathing waxes and wanes with periods of apnea

- CHF, Renal failure, increased ICP

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38
Q

Name this condition:

  • Quick and shallow breaths with apnea breaks
  • Grim prognosis. End of life. [Severe trauma, heat stroke.]
A

Biot’s

39
Q

How do you palpate for symmetric expansion (respiratory excursion)?

A
  • Place both hands on posterior chest with thumbs at T9 and T10. When patient inhales, your hands should go down to T12.
40
Q

What is tactile fremitus?

A

Vibration intensity felt or auscultated on the chest wall with certain spoken words (vocal fremitus). “Ninety nine.”

41
Q

How do you plapate for tactile fremitus? (2)
What are you listening for? (1)
Why does this work?

A
  • Use palmar base of finger or ulnar edge, touch chest while patient says ninety-nine
  • Start over apices and palpate from side to side or compare sides
  • Sound is conducted better through a dense or solid structure than porous so anything that increases density of lung will increase fremitus.
42
Q

What do you percuss first in the lung exam? Where?

A
  • Apices of the lungs

- Down about 9 places on the back

43
Q

When conducting tactile fremitus:

  • What is one thing that would cause the vibrations to be stronger?
  • What is one thing that would cause the vibrations to be harder to detect?
A
  • An accumulation as in pneumonia = vibrations are stronger

- If you have an analectasis (some reason the lung is not explanding) = vibrations are going to be harder to detect.

44
Q

What sound do you hear if you percuss a barrel chest?

A

Hyperresonance. Longer, louder and deeper sound.

45
Q

Diaphragmatic excursion

  • Where?
  • How large?
  • What are you checking?
A
  • The space around T10-T12
  • 3-5cm. A person who does a lot of exercise might have even 7cm.
  • Are lungs symmetrical?
47
Q

Vesicular breath sounds

  • Length of inspiration v. Expiration
  • Sound (3)
  • Normal location
  • Problematic location
A
  • Inspiration is about 2.5x longer than expiration
  • Soft, low-pitched, breezy quality
  • You hear these sounds in the main part of the lung (not along upper spine, not base of the spine)
  • If you hear this in the bases of the lung, you should be worried about pneumonia.
47
Q

Adventitious breath sounds

A

Breath sounds that are “additive” to normal breath sounds.

49
Q

Bronchovesicular breath sounds

  • Length of inspiration / expiration
  • Pitch
  • What do you hear?
  • Where are they considered normal?
A
  • Inspiration = expiration
  • Pitch is moderate
  • A blowing sound
  • At the base of the lung.
50
Q

Ronchi / Sonorous wheezes

  • What does it sound like? (2)
  • Mainly expiration or inspiration?
  • Two causative disease processes
A
  • Low pitched - like snoring
  • Mainly expiration
  • Bronchitis, single bronchus obstruction
51
Q

Fine crackles (rales)

  • 4 sound characteristics
  • Disease processes (3)
A
  • Soft, high-pitched, brief, like rubbing hair together by ear.
  • Restrictive disease
  • Pneumonia
  • CHF
52
Q

Siblant wheeze

  • What does it sound like?
  • Mainly inspiration or expiration?
  • Disease process (2)
A
  • Like a vibrating reed: Highly pitched, musical, squeaking
  • mostly on expiration.
  • Asthma, chronic emphysema
53
Q

Stridor Wheeze

  • What does it sound like?
  • Mainly inspiration or expiration?
  • Disease process (3)
A
  • High pitched crowing
  • Mainly inspiration
  • Croup, acute epiglottis, foreign body inhalation
53
Q

Bronchophony

  • What does it sound like?
  • When does it occur? (One disease)
A
  • “99” is clear rather than muffled.

- Occurs with pneumonia

55
Q

Bronchophony - abnormal

  • What does it sound like? (3)
  • When does it occur? (One disease)
A
  • Low pitched
  • Increased intensity as the pt talks louder
  • “99” is clear rather than muffled.
  • Occurs with pneumonia
56
Q

Egophony.

  • Define
  • What does it sound like?
  • What are you listening for?
A
  • Lung is compressed by fluid, as in pleural effusion. Most sensitive sign for consolidation.
  • High when abnormal, otherwise low.
  • “E” to “A” changes when practitioner listens to vowel sounds through posterior lungs.
56
Q

Front of the chest is mostly ________ breath sounds, except around the _________, and the _______ breath sounds around the trachea.

A

Vesicular
Media steneum
Bronchovesicular

57
Q

Whispered pectoriloquy

  • How do you test it?
  • What will you hear?
  • What might it indicate?
A
  • Pt whispers “99”
  • With stethoscope, it sounds high and clear rather than faint or absent
  • May indicate consolidation
58
Q

Five components of a normal lung

A
  • Trachea is midline
  • Tactile fremitus is normal
  • Percussion is resonant
  • Breath sounds are vesicular except perhaps over bronchi or trachea
  • No adventitious sounds
59
Q 
CONSULTATION
Atelectasis (Lobar instruction): Five things to look for
A
  • Trachea may be shifted to one side
  • Tactile fremitus: usually absent over area of obstruction
  • Percussion: Dull over airless area
  • Breath sounds: Usually absent when bronchial plug
  • Adventitious sounds: None
60
Q

CONSULTATION

Pneumonia: Five things to look for

A
  • Trachea: Midline
  • Tactile fremitus: Increased over involved area with bronchophony, egophony, whispered pectoriloquy
  • Percussion: Dull over airless area
  • Breath sounds bronchial over involved area
  • Adventitious sounds: Late inspiratory crackles over involved area.
61
Q

CONSULTATION

Bronchitis: Five things you’re looking for.

A
  • Trachea: Midline
  • Tactile fremitus: Normal
  • Percussion: Resonant
  • Breath sounds: Vesicular except perhaps over large bronchi or trachea
  • Adventitious sounds: None or scattered coarse crackles in early inspiration and perhaps expiration, wheezes and rhonchi.
62
Q

Emphysema

A
  • Trachea: Midline
  • Tactile fremitus: Decreased
  • Percussion: Hyperresonant
  • Breath sounds: Decreased to absent
  • Adventitious sounds: None or scattered coarse crackles in early expiration; or wheezes and rhonchi associated with chronic bronchitis.
63
Q

Asthma

  • Very similar to _________
  • 3 characteristics
A

Very similar to bronchitis, except asthma also gets bronchial spasms and edema in addition to mucus.

64
Q

Pleural effusion

  • Define
  • Five things you look for.
A

Fluid compresses against the lung

  • Trachea is shifted toward side opposite large effusion
  • Tactile fremitus is decreased to absent
  • Percussion is dull to flat over fluid
  • Breath sounds are decreased to absent, but bronchial sounds may be heard near top of large effusion.
  • Adventitious sounds: None, except for a possible rub.
65
Q

Pneumothorax

  • Two possible causes
  • Five things to look for
A
  • Two kinds of pneumothorax that collapse the lung: Rupture in lung wall or leak in chest wall.
  • Trachea: Shifted toward opposite side if much air
  • Tactile fremitus: Decreased to absent over pleural air
  • Percussion: Hyperresonant to tympanic over pleural air
  • Breath sounds: Decreased to absent over pleural air
  • Adventitious sounds: None, except a possible pleural rub.
66
Q

CHF

  • Define
  • Five things to look for
A

Gorged capillaries because the pressure is building back into the lungs from the heart.

  • Trachea: Midline
  • Tactile fremitus: Decreased
  • Percussion: Resonant
  • Breath sounds: Vesicular
  • Adventitious sounds: Late inspiratory crackles in the dependent portion of lungs. Possibly wheezes.
67
Q

External anatomy of the breast

A
  • Lies between the 2nd and 6th rib
  • Between sternal edge to mid axillary line
  • The nipple is just below center
  • The superior lateral corner called “tail of spence” projects up and into the axilla
69
Q

Three types of tissue in the breast:

1) First tissue
- Tissue type
- Where is it located?
2) Second tissue
- Tissue type
- Function
3) Third tissue
- Location

** Which type predominates?

A

1) Glandiular tissue
- Located into 15-20 lobes surrounding the nipple

2) Fibrous bands of tissue
- including suspensatory ligaments (coopers) which support the glandular tissue

3) Adipose tissue
- Surrounds the breast tissue
* * Predominates the breast tissue.

70
Q

Clinical points of reference (3)

A
  • Look at the breast like a clock. “There is a mass at 12 O’clock”
  • Sometimes discussed like quadrant.
  • Flatten out the breast. Hand behind head, side supported by pillow.
71
Q

Lymphatics: Axillary nodes (4)

A
  • Central axillary nodes: Deep in axilla
  • Pectoral nodes: Anterior, underneath pectoral muscles
  • Subscapular nodes: Back of armpit
  • Lateral axillary nodes: Against the humorous here
72
Q

Breast health history questions (10)

A

1) Pain
2) Lump
3) Discharge from nipples
4) Rashes, redness
5) Swelling
6) Trauma
7) History of breast disease
8) Surgery
9) Breast cancer risk
10) Self-care behaviors (Perform self-breast-exam? Last mammogram?)

73
Q

Objective data - physical exam of breast

- Six things

A
  • Size and symmetry (usually one breast is larger than the other)
  • Countour (masses, dimpling, flattening)
  • Skin color, thickening, edema, venous pattern
74
Q

Retraction maneuvers

A
  • Hand over head
  • Hands on waist, squeeze
  • Bend forward
75
Q

Inspection of the nipple

  • 3 things to look at
  • 4 negative things
A
  • Size
  • Shape
  • Direction they point
  • Discharge?
  • Rashes?
  • Ulcers?
  • Alterations?
76
Q

What is the word for an extra nipple?

A

Supernumerary nipple. Follows the milk line.

77
Q

Breast palpatation

  • Best positition is _______
  • How long should this take?
  • Motion
  • Pay attention to:
A
  • Best position is when tissue is flattened
  • A thorough exam should take 3 minutes per breast or longer
  • Concentric circles
  • Pay attention to the tail of Spence
78
Q

Bimanual breast palpation

A
  • Used with large-breasted women.

- Because their breast tissue never lays very flat.

79
Q

If any notes are present in the breast exam, note (6)

A
  • Location
  • Size
  • Shape
  • Consistency
  • Mobility
  • Distinctness
80
Q

Fibroadenomas

  • What are they?
  • What age group usually gets them?
  • Four characteristics.
A
  • Benign masses in the breast.
  • Usually age 15-25
  • Usually firm, well delineated, non-tender, very mobile.
81
Q

Fibrocystic breast

  • What are they?
  • What age group usually gets them?
  • Four characteristics.
A
  • Soft, tender, mobile lumps in the breast
  • Age 50-30
  • Usually elastic, well delineated, mobile, tender.
82
Q

Breast cancer

  • Configuration (4)
  • What do you palpate (2)?
  • What age group usually gets them?
A
  • Usually single. Usually irregular or stellate. Not clearly deliniated.
  • Firm or hard. Usually nontender.
  • Age 30 or over, most common over 50
83
Q

Tanner stages

A

Stages of breast growth, genitalia development for adolescent girls

84
Q

What is the manubriosternal angle?

  • Other name
  • What is it?
  • Where is it?
A
  • “Angle of Louis”
  • Small bridge of bone
    • At base of manubrium, on the bone where the manubrium turns into the sternum. Located at the second rib and atria of the heart.
85
Q
  • Where is the costal angle?

- What should you check for with this?

A
  • Less than 90 degrees.
  • Greater than 90 degrees would be barrel chested.
  • Under xiphoid process.
85
Q

What is Hemoptysis?

- What four conditions cause it?

A

Coughing up blood

  • Occurs with heart failure
  • definitely with pulmonary embolus.
  • Sometimes with bronchitis or pneumonia
86
Q

______is when the sternum pokes out a little bit

A

Pectus carinatum

87
Q

Vertebral issue, prevents the lungs from being able to fully inflate

A

Scholiosis

88
Q

____ is a spine disorder in elderly, usually due to ______. Hunchback.

A

Kyphosis - usually due to osteoperosis

89
Q

Four functions of changing chest size

A
  1. Supply Oxygen to body for energy production
  2. Remove CO2 as a waste product
  3. Maintain acid-base balances of arterial blood
  4. Maintain heat exchange
91
Q

Bronchial (tubular) breath sounds

  • Inspiration to expiration ratio
  • What do they sound like?
  • Where are they considered normal?
A
  • Inspiration < Expiration (1:2)
  • High pitch, Like air blown through a hollow tube
  • Considered normal over the trachea
92
Q

Coarse crackles

  • How do they compare to fine crackles (3)?
  • Sounds (3)
  • Disease processes (3)
A
  • Somewhat louder, lower, longer than fine crackles
  • Bubbling, gurgling, velcro
  • Pulmonary edema, pneumonia, atelectasis
93
Q

Name the organ you would normally associate with each type of percussion resonance:

1) Resonant
2) Hyperresonant
3) Tympany
4) Dull
5) Flat

A

1) Over normal lung tissue
2) Over lungs with increased amount of air (child’s lung - abnormal in adult)
3) Air-filled viscus (eg stomach, intestine)
4) Dense organ (eg liver, spleen)
5) No air present - thigh muscles, bone, tumor.

94
Q

Five factors that increase the risk for breast cancer.

A
  • No children
  • childbearing after the age of 30
  • alcohol
  • obesity
  • personal or family history of breast, ovarian or colon cancer
95
Q

If you find any abnormalities in the breast exam, you should go onto look for (5):

A
  • Nipple characteristics
  • Overlying skin (erythema, dimpling, retraction)
  • Tenderness
  • Lymphenopathy
  • Heart

PA: Exam 1 (10 decks)

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