Chest Exam: Thorax and Lungs Flashcards
1
Q
Thorax landmarks: Anterior and Posterior
A
Anterior -Rib cage, sternum, suprasternal notch, clavicle, nipples -Sternal angle (Angle of Louis) @ 2nd intercostal space -Imaginary reference lines Posterior -C 7 -Tip of scapula @ 7th intercostal space -Imaginary reference lines
2
Q
Thorax landmarks: Ribs
A
Ribs 1-7 attached to sternum Ribs 8-10 attach to cartilage of rib above “Floating” ribs – 11 & 12 Costal (costophrenic) angle anterior Costovertebral angle (CVA) posterior
3
Q
Reference lines
A
Anterior thorax
- Mid sternal line
- Mid clavicular line
- Nipple line (T4)
Lateral thorax
- Anterior axillary line
- Midaxillary line
- Posterior axillary line
Posterior thorax
- Vertebral line
- Midscapular line
4
Q
diaphragm
A
dome shaped muscle located at base of lung fields, primary breathing muscle
Moves down/contracts with inspiration, up/relaxes with expiration
5
Q
lung apex location
A
2-4 cm above inner third of clavicle
6
Q
Lower border of lung (during inspiration) location
A
6th rib anteriorly MCL
T10 posteriorly MSL
7
Q
pleural fluid
A
between parietal and visceral pleura
allows lungs to move easily with inspiration and expiration
8
Q
how pain is felt in lungs
A
Pleural space has pain fibers (irritants…inflammation…pain)
Lung tissue itself has no pain fibers; however, surrounding structures do (ie: pleura, muscles, bones)
9
Q
repiratory inspection
A
- Check for Respiratory Difficulty
- Assessment of color
- Observe patient’s posture
- Inspect the nose for nasal flaring
- Inspect the neck for accessory muscle use
- Inspect the rib cage for retractions
- Observe the shape of the chest, AP diameter
10
Q
thorax inspection
A
Anterior & Lateral
- Ratio of anterior/posterior to lateral (transverse) diameter is normally 1:2
- Symmetry of respiratory movements
Posterior
- Deformity or spinal curvature
- Symmetry of respiratory movements
11
Q
barrel chest
A
COPD, emphysema, and chronic bronchitis
12
Q
kyphosis
A
elderly and can be congenital
can impact lung function
13
Q
pectus excavatum
A
caved in chest wall
congenital abnormality
can impact lung development and lead to respiratory problems
14
Q
pectus carnatum
A
less of an issue with lung function
15
Q
palpation of thorax
A
Assess for :
- Masses
- Tenderness
- Crepitus
- Respiratory Expansion
- Tactile Fremitus
16
Q
Respiratory expansion
A
-Indicates equal expansion of lungs during a normal respiratory cycle
-Assesses compliance of lungs, pleura and chest musculature
-Place thumbs at level of the 10th ribs
Slide hands medially…raise loose fold of skin.
Ask pt to inhale deeply
Watch thumbs move apart at pt inhale
Feel for symmetry and range of rib cage as it expands and retracts
17
Q
tactile fremitus
A
- Use either ball or ulnar aspect of hand
- Ask the patient to say “99” or “1-1-1”
- Examine the Fields
- -Four fields posteriorly
- -Three fields anteriorly
- Palpable vibrations transmitted from the bronchopulmonary tree to the chest wall
- Look for asymmetrical difference in the intensity of the vibratory sensation
- More solid areas of lung will transmit more vibrations (Increased fremitus suggests fluid, mass, pneumonia)
18
Q
percussion
A
- Screen the ant/lat/post thorax noting any change in the normal resonant sound
- Helps to determine if structures are air filled, fluid filled, or solid
- Compare bilaterally moving side to side
19
Q
percussion sound: resonant
A
healthy lung tissue
20
Q
percussion sound: flat/dull
A
effusion or consilidation (fluid or solid has replaced air containing lung or occupies pleaural space)
21
Q
percussion sound: hyper-resonant
A
emphysema, pneumothorax, acute asthma
22
Q
percussion sound: tympanic
A
large pneumothorax
23
Q
auscultation
A
- Assess air flow through tracheobronchial tree
- Listening to sounds generated by breathing
- Listening for adventitious (added) breath sounds
- If you hear abnormal breath sounds, you should then listen to spoken/whispered voice sounds as they are transmitted through the chest wall
24
Q
auscultation sound transmission
A
- Normal air-filled lung acts as a filter to sound
- Lung pathology will alter the sound transmission
25
normal tracheal breath sounds
- Heard directly over trachea and neck
- Very loud/high pitched
- Expiratory/inspiratory component equal
26
normal bronchial breath sounds
- Heard directly over a major bronchus
- Loud/high pitched
- Short silence between inspiration & expiration with expiration lasting longer
27
normal bronchovesicular breath sounds
- Heard best in 1st and 2nd ICS anteriorly and between scapula posteriorly
- Medium pitch
- Equal inspiration/expiration
28
normal vesicular breath sounds
- Heard over lung fields
- Soft low pitch
- Inspiration last longer than expiration
29
rales/crackles
- Intermittent, nonmusical dots in time
- Can be fine or coarse, dry or wet
- Crackling noises caused by deflated, fluid filled small airways popping open with air
- Can be heard with pneumonia, fibrosis, bronchitis
30
wheezes/rhonchi
- Musical continuous sounds
- Wheezes suggest narrowed bronchi
- Rhonchi suggest secretions
31
stridor
Stridor: high pitched wheeze during inspiration that is louder at the neck, indicates upper airway obstruction
32
pleaural friction rub
Pleural Friction Rub: discrete “creaking noise” confined to one area, caused by pleural surfaces grating against each other
33
mediastinal crunch
Mediastinal Crunch: (Hamman’s sign) precordial crackles caused by air between pleurae
34
bronchophony
- Bronchophony –Ask patient to say “99” and listen with stethoscope
- -Normal: sound is muffled by healthy lung
- -Increased transmission of voice sound (loud & clear) suggests that air-filled lung has become airless (this is bronchophony)
35
egophony
Egophony – ask patient to say “EE” while listening with stethoscope
If EE is heard as AY and quality is nasal, suggestive of pneumonia or other consolidation
36
whispered pectoriloquy
Whispered Pectoriloquy – ask patient to whisper “99” while listening with stethoscope
Normal: should be barely audible
Easily audible (loud & clear) suggests consolidation
37
summary of lung exam
```
Inspection
-Position, color, AP diameter, accessory muscle use
Palpation (crepitus, tenderness, mass)
-Anterior, posterior, lateral
-Respiratory expansion
Percussion (resonant sound)
-Anterior (apex), posterior (cross arms), lateral
Auscultation (bronchovesicular sounds)
-Anterior, posterior, lateral
```
38
peak flow
Forced expiratory flow rate
Assess for obstructive lung
disease (COPD, asthma)
39
common pulmonary diseases
Chronic Obstructive Pulmonary Disease (COPD)
COPD = chronic bronchitis & emphysema
Chronic bronchitis – excessive mucus production in bronchi
Emphysema – over distention of alveoli, with alveolar destruction
Asthma
Pneumothorax
Pneumonia
40
COPD
Physical findings include
- General inspection: clubbing, cyanosis, accessory muscle use
- Thoracic inspection: barrel chested habitus, increased AP diameter
- Percussion: hyperresonant
- Auscultation: decreased breath sounds
- -Adventitious sounds – none; or crackles, wheezes and rhonchi
41
Asthma
- Hyper-reactivity of bronchial tree resulting in inflammation, hypersecretions and bronchoconstriction
- No structural or permanent damage
- Can be asymptomatic with exacerbations or
- -Mild intermittent
- -Mild persistent
- -Moderate persistent
- -Severe persistent
42
physical findings of asthma
```
Not during attack
-Normal exam
During attack
-Increased RR, HR; decreased O2 saturation
-Tripod position, cyanosis, accessory muscle use
-Resonant percussion note
-Wheezes on auscultation
-Decreased peak flow
```
43
pneumothorax
-Air leakage into the pleural space causes pressure gradient between space and lung
44
Tension pneumothorax
is when the entire lung collapses other lung get shifted over and you get tracheal deviation
45
spontaneous pneumothorax
due to spontaneous rupture of bleb (bulla)
46
traumatic pneumothorax
due to penetrating injury to lung from knife, bullet, or rib fragments
47
physical findings of pneumothorax
- Chest rise is asymmetrical
- Hyperresonant percussion note over affected lung
- Breath sounds decreased or absent over affected lung
- Tactile fremitus decreased or absent over affected lung
- Tension pneumo: tracheal deviation
48
Pneumonia
- Inflammation of lung tissue caused by bacterial, viral or mechanical causes
- Alveoli fill with fluid or purulent debris
49
physical findings of a pneumothorax
- Inspection: normal unless respiratory distress
- Percussion: dull percussion note
- Auscultation: bronchial breath sounds, inspiratory rales
- Transmitted sounds (bronchony, egophony and whispered pectoriloquy) present/increased
- Increased tactile fremitus
50
thorax and lung exam checklist
- fully expose the thorax and inspect for symmetry, lesions, effort of breathing
- inspect the lateral thorax for AP diameter
- palpate anterior, posterior, lateral thorax for tenderness, crepitus
- assess respiratory expansion and tactile fremitus ant/post/lat thorax
- percuss ant/post/lat thorax for symmetry and resonance
- auscultate ant/post/lat thorax
- examine patient bilaterally, comparing sides during percussion and auscultation
- instruct the patient properly during exam (arm crossed, mouth open)
- palpate, percuss, and auscultate in correct and sufficient areas for complete exam
- special tests: egophony, bronchophony, whispered pectoriloquy
