Chapter 11: Chest And Lungs

Question 1

Physical exam: chest

Answer 1

Inspect the chest; front and back, noting thoracic landmarks.
-Size and shape (anteroposterior diameter compared with the lateral diameter)
-Symmetry
-Color
-Superficial venous patterns
-Prominence of ribs

Evaluate respirations.
-Rate
-Rhythm or pattern

Note any audible sounds with respiration.

Palpate the chest.
-Thoracic expansion
-Sensations such as crepitus, grating vibrations
-Tactile fremitus

Perform direct or indirect percussion on the chest, comparing sides.
-Diaphragmatic excursion
-Percussion tone intensity, pitch, duration, and quality

Auscultate the chest with the stethoscope diaphragm, from apex to base; comparing sides.
-Intensity, pitch, duration, and quality of breath sounds
-Adventitious breath sounds (crackles, rhonchi, wheezes, friction rubs)
-Vocal resonance

Question 2

HPI chest and lungs

Answer 2

Cough
-Onset, dry or moist, frequency, regularity, pitch/loudness, quality, sputum

Shortness of breath
-Onset, pattern, severity, associated symptoms
-Position most comfortable, relationship to activity, harder to inhale or exhale, efforts to treat

Chest pain
-Onset, duration, associated symptoms, efforts to treat, medications

Question 3

PMH chest and lungs

Answer 3

Thoracic trauma or surgery, hospitalization for pulmonary disorders

Oxygen or ventilation-assisted devices
-CPAP, BiPAP

Chronic pulmonary diseases

Other chronic disorders

Immunization
-Streptococcus pneumoniae
-Influenza

Question 4

FMH chest and lungs

Answer 4

Allergy, asthma, atopic dermatitis

Cystic fibrosis

Clotting disorders (risk of pulmonary embolism)

Emphysema

Bronchiectasis

Bronchitis

Malignancy

Tuberculosis (TB)

Question 5

PMH/SMH chest and lungs

Answer 5

Employment

Home environment

Nutritional status

Exercise tolerance

Hobbies

Regional/travel exposures

Use of complementary/alternative therapies

Tobacco use

Use of alcohol/drugs

Exposure to respiratory infections, influenza, tuberculosis

Question 6

Chest and lung hx for infants and children

Answer 6

Prematurity; low birth weight; steroids

Immunization
-Pneumococcal
-Annual influenza

Bronchiolitis

Asthma

Swallowing dysfunction
-Gastroesophageal reflux

Sudden-onset cough or difficulty breathing
-Possible ingestion of kerosene, antifreeze or hydrocarbons in household cleaners
-Choking foreign body

Apnea

Question 7

Chest and lung preg pt hx

Answer 7

Weeks of gestation

Multiple fetuses/polyhydramnios/other conditions

Exercise type and energy expenditure

Respiratory infections; influenza immunization

Question 8

Chest and lung Hx older adults

Answer 8

Respiratory infections

Oxygen therapy

Effects of weather

Immobilization

Swallowing issues, choking, coughing

Change in ADL

Signs/symptoms of chronic respiratory diseases

Question 9

Chest and lung inspection

Answer 9

Chest
-Shape and symmetry
-Chest wall movement
-Superficial venous patterns
-Prominence of ribs
-Anteroposterior versus transverse diameter -Barrel chest
-Sternal protrusion; spinal deviation

Respiration
-Rate
-Quality
-Pattern

Count rate while palpating pulse.

Inspect the chest wall during respiration.
-Symmetry
-Retractions

Peripheral clues may suggest pulmonary or cardiac difficulties.
-Fingers: clubbing
-Breath: odor
-Skin, nails, and lips: cyanosis or pallor
-Lips: pursing
-Nares: flaring

Question 10

Chest and lung palpation

Answer 10

Thoracic muscles/skeleton
-Pulsations, tenderness, masses, bulges/depressions, unusual movement/positions, elasticity of rib cage, immovability of sternum, rigidity of thoracic spine

Crepitus
-Crackly or crinkly sensation, can be both palpated and heard
-Indicates air in the subcutaneous tissue -> Rupture somewhere in the respiratory system, Infection with a gas-producing organism

Friction rub
-Palpable, coarse, grating vibration, usually on inspiration

Thoracic expansion
-Loss of symmetry in the movement of the hands with the thumbs at the level of the 10th rib suggests a problem on one or both sides

Tactile fremitus
-Palpable vibration of the chest wall that results from speech or other verbalizations

Note the position of the trachea.

Question 11

Percussion chest and lung

Answer 11

Percuss chest.
-Anterior, lateral, posterior
-Compare tones bilaterally.

Measure diaphragmatic excursion.
-Descent may be limited by several types of pathologic processes: pulmonary, abdominal, superficial pain.

Percussion tone indicators for lungs
-Resonance is normal.
-Hyperresonance indicates hyperinflation.
-Dullness indicates diminished air exchange.

Percussion notes
-Intensity, pitch, quality, duration

Question 12

Breath sounds chest and lung

Answer 12

Vesicular
-Low-pitched, low-intensity; heard over healthy lung tissue

Bronchovesicular
-Heard over the major bronchi; moderate in pitch and intensity

Bronchial
-Highest in pitch and intensity
-Ordinarily heard only over the trachea

Both bronchovesicular and bronchial
-Abnormal if heard over peripheral lung tissue

Amphoric versus cavernous
-Unexpected sounds

Vocal resonance
-Voice transmits sounds through lung fields, heard with the stethoscope.
-Auditory changes: Bronchophony, pectoriloquy, egophony. Diminishes/loses intensity with loss of tissue in respiratory tree (e.g., with the barrel chest of emphysema)

Question 13

Adventitious breath sounds

Answer 13

Crackles (formerly called rales)
-Heard more often during inspiration and characterized by discrete discontinuous sounds
-Fine: high pitched and relatively short in duration
-Coarse: low pitched and relatively longer in duration

Rhonchi (sonorous wheezes)
-Deeper, rumbling, pronounced during expiration, prolonged and continuous, less discrete than crackles
-Caused by the passage of air through an airway obstructed by thick secretions, muscular spasm, tumor, or external pressure

Wheezes (sibilant wheeze)
-Continuous, high-pitched, musical sound (almost a whistle) heard during inspiration or expiration
-Caused by a relatively high-velocity airflow through a narrowed or obstructed airway
-May be caused by the bronchospasm of asthma (reactive airway disease) or acute or chronic bronchitis

Friction rub
-Occurs outside the respiratory tree
-Dry, crackly, grating, low-pitched sound; heard in both expiration and inspiration
-Caused by inflamed, roughened surfaces rubbing together

Mediastinal crunch (Hamman sign)
-Found with mediastinal emphysema
-Loud crackles, clicking and gurgling; synchronous with the heartbeat and not respiration

Question 14

Patterns of resp

Answer 14

Normal: regular an comfortable at a rate of 12-20 breaths per min

Bradypnea: slower than 12 per min

Tachypnea: faster than 20 per min

Hyperventilation: (hyperpnea) faster than 20 breaths per min, deep breathing

Sighing: frequently interspersed deeper breath

Air trapping: increasing difficulty in getting breath out

Cheyne-strokes: varying periods of increasing depth interspersed with apnea

Kussmaul: rapid, deep, labored

Boot: irregularly interspersed periods of apnea in a disorganized sequence of breaths

Ataxic: significant disorganization with irregular and varying depths

Question 15

Physical exam: infants

Answer 15

Inspection
-Chest expansion for asymmetry
-Respiratory rate varies between 40 and 60 respirations per minute.
-Periodic and paradoxical breathing
-Sneezing, hiccups are common
-Palpate the clavicle, rib cage and sternum, noting loss of symmetry, unusual masses, or crepitus.

Auscultate the chest.
-Stridor: high-pitched, piercing sound most often heard during inspiration
-Due to obstruction high in the respiratory tree

Work of breathing: an infant’s effort to breathe
-Decreased feedings
-Increased respiratory rate
-Retractions -> Suprasternal, Subcostal, Intercostal
-Respiratory grunting
-Nasal flaring
-Grunting (an attempt to maintain positive end expiratory pressure)

Question 16

Physical exam: children

Answer 16

Thoracic (intercostal) musculature for respiration occurs by 6 or 7 years.

Variable respiratory rate, decreasing with age, reaching adult rates at 17 years

Roundness of chest persisting past second year may indicate pulmonary problem

Breath sounds
-Bronchovesicular sounds may predominate.

Question 17

Preg pt physical exam

Answer 17

Structural and ventilatory changes

Dyspnea

Deeper breathing

Question 18

Physical exam: older adults

Answer 18

Decreased chest expansion, muscle weakness, physical disability, sedentary lifestyle, rib articulation calcification

Marked bony prominences, kyphosis, increased anteroposterior diameter

Question 19

Chest/Respiratory Abnormalities

Answer 19

Asthma
Small airway obstruction, airway inflammation, and excess mucus production

Atelectasis
Incomplete expansion of the lung at birth or the collapse of the lung at any age

Bronchitis
Inflammation of the large airways

Pleurisy
Inflammatory process involving the visceral and parietal pleura

Pleural effusion
Excessive nonpurulent fluid in the pleural space

Empyema
Purulent exudative fluid collected in the pleural space

Lung abscess
Well-defined, circumscribed, inflammatory, purulent mass that can develop central necrosis

Pneumonia
Inflammatory response of the bronchioles and alveoli to an infective agent (bacterial, fungal, or viral)

Influenza
Viral infection of the lung; secondary bacterial infection

Tuberculosis
Chronic infectious disease that most often begins in the lung but may then have widespread manifestations

Pneumothorax
Presence of air or gas in the pleural cavity

Hemothorax
Presence of blood in the pleural cavity

Influenza
Viral infection of the lung; secondary bacterial infection

Lung cancer
Bronchogenic carcinoma, a malignant tumor that evolves from bronchial epithelial structures

Pulmonary embolism
Embolic occlusion of pulmonary arteries; common
condition; difficult to diagnose

Epiglottitis
Acute, life-threatening infection involving the epiglottis and surrounding tissue

Question 20

Abnormalities in Infants, Children, and Adolescents

Answer 20

Diaphragmatic hernia
Imperfectly structured diaphragm

Tracheomalacia
Lack of rigidity/floppiness of the trachea or airway

Chronic lung disease
Result of prematurity

Cystic fibrosis
Autosomal recessive disorder of exocrine glands involving the lungs, pancreas, and sweat glands

Bronchiolitis
Bronchiolar (small airway) inflammation leading to hyperinflation of the lungs occurring in infants younger than 6 months

Croup (laryngotracheal bronchitis)
Syndrome that results in infection from viral agents occurring most often in children ≤3 years of age

Asthma

Question 21

Abnormalities in Older Adults

Answer 21

Chronic obstructive pulmonary disease (COPD)
Group of respiratory problems; cough, chronic/excessive sputum production; dyspnea
Smokers at greatest risk

Emphysema
Lungs lose elasticity; alveoli enlarge.

Bronchiectasis
Chronic dilation of bronchi/bronchioles caused by pulmonary infections/bronchial obstruction

Chronic bronchitis
Large airway inflammation

Question 22

A loud bubbly noise heard during auscultation is:

Course crackles
Fine crackles
Rhonchi
Plural friction rub

Answer 22

ANS: A

Rationale: Course crackles are loud bubbly noises heard during auscultation and best heard during inspiration.

Question 23

Laryngeal obstructions would elicit which breath sound?

Fremitus
Stridor
Rhonchi
Wheezing

Answer 23

ANS: B

Rationale: Obstructions high in the respiratory tree are characterized by stridor.

Question 24

Mr. Mackey is a 42-year-old patient who presents with the complaint of cough with blood. On examination you note crackles and rhonchi that clear with coughing. You anticipate a diagnosis of:

Acute bronchitis
Bronchiectasis
Chronic bronchitis
Emphysema

Answer 24

ANS: B

Rationale—Chronic dilation of the bronchi and bronchioles is caused by repeated pulmonary infections and this results in hemoptysis crackles and rhonchi.

Question 25

Mrs. Brant, a 58-year-old women, presents with a complaint of fever and dyspnea. She admits to previous history of smoking; however, she quit smoking 10 years ago. The healthcare provider diagnoses her with lobular pneumonia, and you begin to plan care for Mrs. Brant.

What is the etiology of lobular pneumonia?

Aspiration of infected food
Pulmonary parenchyma infection
Interstitial infection
Disorder of connective tissue

Answer 25

ANS: B

Rationale: Pneumonia is the acute infection of the pulmonary parenchyma that may be caused by a variety of organisms, depending in part on the setting in which the pneumonia was acquired.

Question 26

Mrs. Brant, a 58-year-old women, presents with a complaint of fever and dyspnea. She admits to previous history of smoking; however, she quit smoking 10 years ago. The healthcare provider diagnoses her with lobular pneumonia, and you begin to plan care for Mrs. Brant.

What two types of adventitious sounds would you expect to hear when assessing Mrs. Brant?

Crackles and rhonchi
Crackles and wheezing
Pleural friction rub and rhonchi
Wheezing and pleural friction rub

Answer 26

ANS: A

Rationale: In pneumonia diminished breath sounds with crackles and rhonchi are common.

Question 27

Mrs. Brant, a 58-year-old women, presents with a complaint of fever and dyspnea. She admits to previous history of smoking; however, she quit smoking 10 years ago. The healthcare provider diagnoses her with lobular pneumonia, and you begin to plan care for Mrs. Brant.

During palpation and percussion of the chest, you would expect to find:

Decreased fremitus and tympanic tones
Increased fremitus and dull tones
Decreased fremitus and dull tones
Normal fremitus and flat tones

Answer 27

ANS: C

Rationale: In pneumonia you would expect to find decrease fremitus and dull tones when consolidation is present.