Block 4 Flashcards
The first palpable rib
2nd rib, at the level of the sternal angle
Costal cartilages of 1-7 ribs articulate with?
the sternum
Cartilages of 8th, 9th , and 10th ribs articulate with ?
the costal cartilages just above them
Ribs ______ are “floating”, - no anterior attachments
Ribs 11 and 12
Tip of 11 – felt _____
laterally
Tip of 12 – felt _____
more posteriorly
Inferior tip of scapula – at the level of ?
7th rib or interspace
most prominent vertebrae
C7 is the most prominent vertebrae, it is followed by T1
– drop vertically from the anterior and posterior axillary folds
Anterior and Posterior axillary lines
– drops from the apex of the axilla
Midaxillary line
- along spinous process
Vertebral line
– from inferior angle of scapula
Scapular line
Apex rises _______cm above the clavicle
2 -4cm
The lower border of the lung crosses the ?
6th rib – 8th rib
The lung descends or ascends during inspiration?
Descends
The lower border of the lung crosses the 6th rib at the _____ and 8th rib at the _____
The lower border crosses the 6th rib at the MCL and 8th rib at the MAL
Posteriorly, the lower border of the lungs is about the level of ?
T10
- above the clavicles
Supraclavicular
– below the clavicles
Infraclavicular
– between the scapulae
Interscapular
– below the scapulae
Infrascapular
– lowermost portions
Bases of the lungs
The trachea bifurcates into its mainstem bronchi at the levels of the _____ anteriorly…
Sternal Angle
The trachea bifurcates into its mainstem bronchi at the levels of the _____ posteriorly…
T4 Spinous Process
Pursed lip
COPD
Creates pressure and keeps airways open
Seen in Difficulty of Breathing, widened nostrils for air seen in infants
Nasal flaring
Supraclavicular fossae – is it an acute or chronic finding?
chronic finding
Accessory muscles of breathing:
sternocleidomastoid
scalene
serratus anterior
Anteroposterior diameter is increased due to air trapping
Seen in COPD patients
AP>Transverse diameter
Barrel Chest
structural deformity of the anterior thoracic wall in which the sternum and rib cage are shaped abnormally
This produces a caved-in or sunken appearance of the chest.
Pectus Excavatum
“pigeon chest”
Protrusion of the sternum and ribs
Pectus Carinatum
Configuration in whch one chest wall moves paradoxically inward during inspiration
Seen in 2-point fracture of the same rib
Distal and proximal ends of the rib
trauma
Flail Chest
Why? Inspiration – negative pressure – sucks flail segment out
Expiration – positive pressure – flail segment pushed out
Is it okay to ask the patient to breathe normally?
Never ask the patient to breathe “normally”
Patient becomes anxious or conscious, thus voluntarily change their breathing patterns and rates
A better way is to direct your eyes to the patient’s chest after taking the radial pulse
Seen in exercise, anxiety, and metabolic acidosis
Rapid Deep Breathing (Hyperpnea, Hyperventilation)
is deep breathing due to metabolic acidosis. It may be fast, normal, or slow
Kussmaul breathing
What to consider in Rapid Deep Breathing (Hyperpnea, Hyperventilation)?
Consider infarction, hypoxia, or hypoglycemia
Mechanism of Rapid Deep Breathing (Hyperpnea, Hyperventilation) in renal failure?
Usually in renal failure -> decrease in plasma bicarbonate -> acidosis -> compensatory increase in ventilation mitigates the fall in systemic pH -> blow off co2
An oscillation of ventilation between apnea and hyperpnea with a crescendo-decrescendo pattern
Periods of deep breathing alternate with periods of apnea (no breathing)
Associated with changing serum partial pressures of oxygen and carbon dioxide
Brain tumor, stroke
Pons
Cheyne-Stokes Breathing
Seen in brain tumors, stroke -> affected respiratory centers
Cheyne-Stokes Breathing
Begins with hyperventilation -> blow of CO2 -> triggers apnea ->Rise in CO2 -> hyperventilation recurs -> cycle repeats
Cheyne-Stokes Breathing
Characterized by unpredictable irregularity
Breaths may be shallow or deep, and stop for short periods
Causes: respiratory depression and brain damage typically at the medullary level
Most commonly seen in meningitis
Biot’s Breathing (Ataxic Breathing)
used to assess patients with CNS depression
Cheyn Stokes and Biots
– Medulla
Biots
– Pons
Cheyn Stokes
- Rapid Gasping + apnea
Biot’s
- Increase and Decrease + Apnea
Cheyn Stoke’s
“chest pain” may musculoskeletal –
costochondritis
How to do Chest Lag Test for Lung Excursion?
Place your thumbs at about the level of the 10th ribs, with fingers loosely grasping and parallel to the lateral rib cage
Slide your hands slightly medially just enough to raise a loose fold of skin
Ask the patient to inhale deeply
Watch the distance between your thumbs as they move apart
Check for symmetry
Localized pulmonary disease may cause one side of the chest to move less than the opposite
palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as the patient speaks
Fremitus
Use the _____ surface of the hand in palpating fremitus
ulnar
Locations of palpating fremitus
Image
Transmission of fremitus is increased in what conditions?
in conditions that increase the density of the lung
Consolidation
Mass
Fremitus is decreased as it travels through liquid or air:
Examples of conditions—–
Pneumothorax
Pleural effusion
sound travels faster in what medium?
sound travels faster through solid
Percussion Penetrates only up to ____cm
5cm to 7cm
How to perform percussion?
Hyperextend the middle finger of your left hand (pleximieter finger)
Press its distal interphalangeal joint firmly on the surface to be percussed
Other fingers should not be touching the chest
With a quick, sharp but relaxed wrist motion, strike the pleximeter finger with the right middle finger (plexor finger)
Strike using the tip of the plexor, not the finger pad
Pattern of Percussion
Image
thigh on percussion
Flat –
liver on percussion
Dull –
Normal lung on percussion
Resonant –
COPD on percussion
Hyperresonant –
- stomach on percussion
Tympanitic
replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space
Dullness
Condition with dull percussion
Lobar pneumonia
Pleural effusion
Hemothorax
Empyema
– heard over hyperinflated lungs
Generalized Hyperresonance
Conditions with generalized hyperresonance
COPD or Asthma
Unilateral hyperresonance in?
Large pneumothorax
barrel chest
COPD –
How to check for Descent of Diaphragm (Diaphragmatic Excursion)?
Hold the pleximeter finger above and parallel to the expected level of dullness
Percuss downward until dullness clearly replaces resonance
An abnormally high level of diaphragm suggests?
pleural effusion, or a high diaphragm as in phrenic nerve paralysis
Pattern of auscultation
Image
The most important examination technique for assessing air flow through the tracheobronchial tree
Auscultation
Breath sounds:
Vesicular
Bronchovesicular
Bronchial
Adventitious breath sounds:
Crackles
Wheezes
rhonchi
Soft, low pitched sounds heard over most of the lung field
Produced by air moving through the small bronchioles and alveoli
Inspiratory component is much longer than the expiratory component
Vesicular
Mixture of bronchial and vesicular sounds
Inspiratory and expiratory components are equal in length
Normally heard in the first and second interspaces anteriorly, and between the scapulae posteriorly (mainstem bronchi)
Bronchovesicular
Loud, high pitched, and sound like air rushing through a tube
Expiratory component is louder and longer than the inspiratory component
Normally heard over the manubrium (over the trachea)
Bronchial
Harsh, loud, high-pitched sounds heard over the extrathoracic trachea
Inspiratory and expiratory components are approximately equal
Tracheal
Short, discontinuous, nonmusical sounds heard mostly during inspiration
Caused by opening or expansion of collapsed distal airways and alveoli due to secretions
“Rubbing hair next to ear”
Crackles/Rales or crepitation
Inspiratory phase
High pitch
hair
Fine:
Both phases
Low pitch
bubble
Coarse:
Continous, high-pitched sounds heard mostly during expiration
Produced by turbulent airflow through narrowed bronchi
Swelling, secretions, tumor, foreign body
Bronchospasm of asthma
Wheeze
Can wheezing be both inspiratory and expiratory?
Can be both inspiratory and expiratory - worse
Lower pitched, more sonorous lung sounds
“snoring” quality
More common with transient mucus plugging and poor movement of airways
Rhonchi
Low pitch and continuous (insp/exp) compared to wheezing
Occurs when air passes through large airways filled with secretions -> turbulent fow
Cleared with coughing (secretions)
Rhonchi
Grating sound produced by motion of pleura, which is impeded by frictional resistance
When pleural surfaces are roughened or thickened
Pleuritis/pleurisy
Best heard: end of inspiration and beginning of expiration
Creaking leather
Pleural Rub
Mechanism:
Crackles
Alveolar secretions
Mechanism:
Wheeze
Airflow through obstructed airway
“whistle”
Mechanism:
Rhonchi
Airway plugging;
Turbulent flow through large airway secretions
Mechanism:
Pleural Rub
Inflammation of the pleura, loss of lubrication
Causes:
Crackles
Bronchitis, pneumonia, pulmonar9y edema, atelectasis
Causes:
Wheeze
Asthma
Bronchitis
Causes:
Rhonchi
Bronchitis
Causes:
Pleural Rub
Pleuritis, Pneumonia
Is an increased resonance of voice sounds
Enhanced transmission of high-frequency sound across fluid
Caused by consolidation, pleural effusion and fibrosis
E to A transition
Egophony
Intensification of the whispered word heard
Instruct the patient to whisper “one two three”, while examiner listen to the area suspected of consolidation
Normally, whispering produces high-pitched sounds that are filtered out by the lungs, so nothing is heard
If consolidation is present, whispered words are louder and clearer
Whispered Pectoriloquy
Increased transmission of spoken words heard in the presence of consolidation of the lungs
Says “ninety-nine”, while the examiner listens
If bronchophony is present, words are transmitted more loudly than normally
Bronchophony or “Tactile Fremitus”
Same as whispered pectoriloquy, but spoken instead of whispered
Bronchophony or “Tactile Fremitus”
Inreased vocal fremitus =
increased tactile fremitus also
- The clerk notes that a client has periods of deep breathing alternating with periods of apnea. He documents the presence of which of the following?
Cheyne-Stokes respirations
Dyspnea
Kussmaull’s
Biot’s (Ataxic breathing)
Cheyne-Stokes respirations
