Chapter 11: Chest And Lungs Flashcards
Physical exam: chest
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
HPI chest and lungs
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
PMH chest and lungs
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
FMH chest and lungs
Allergy, asthma, atopic dermatitis
Cystic fibrosis
Clotting disorders (risk of pulmonary embolism)
Emphysema
Bronchiectasis
Bronchitis
Malignancy
Tuberculosis (TB)
PMH/SMH chest and lungs
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
Chest and lung hx for infants and children
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
Chest and lung preg pt hx
Weeks of gestation
Multiple fetuses/polyhydramnios/other conditions
Exercise type and energy expenditure
Respiratory infections; influenza immunization
Chest and lung Hx older adults
Respiratory infections
Oxygen therapy
Effects of weather
Immobilization
Swallowing issues, choking, coughing
Change in ADL
Signs/symptoms of chronic respiratory diseases
Chest and lung inspection
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
Chest and lung palpation
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.
Percussion chest and lung
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
Breath sounds chest and lung
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)
Adventitious breath sounds
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
Patterns of resp
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
Physical exam: infants
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)
Physical exam: children
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.
Preg pt physical exam
Structural and ventilatory changes
Dyspnea
Deeper breathing
Physical exam: older adults
Decreased chest expansion, muscle weakness, physical disability, sedentary lifestyle, rib articulation calcification
Marked bony prominences, kyphosis, increased anteroposterior diameter
Chest/Respiratory Abnormalities
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
Abnormalities in Infants, Children, and Adolescents
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
Abnormalities in Older Adults
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
A loud bubbly noise heard during auscultation is:
Course crackles
Fine crackles
Rhonchi
Plural friction rub
ANS: A
Rationale: Course crackles are loud bubbly noises heard during auscultation and best heard during inspiration.
Laryngeal obstructions would elicit which breath sound?
Fremitus
Stridor
Rhonchi
Wheezing
ANS: B
Rationale: Obstructions high in the respiratory tree are characterized by stridor.
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
ANS: B
Rationale—Chronic dilation of the bronchi and bronchioles is caused by repeated pulmonary infections and this results in hemoptysis crackles and rhonchi.
