Exam 1 Flashcards
4+ Pulse
Bounding
3+ Pulse
Full, Increased
2+ Pulse
Normal
1+ Pulse
Weak, thread
0 Pulse
Abscent
Corresponding Vertebral Bodies Manubrium
T3
Corresponding Vertebral Bodies Aorta
T4
Corresponding Vertebral Bodies Heart
T4/T6 - T9
Cardiac Auscultation Aortic Area
2nd intercostal space, right sternal border
Cardiac Auscultation Pulmonic Area
2nd intercostal space, left sternal border
Cardiac Auscultation Tricuspid Area
4th or 5th intercostal space, left or right sternal border
Cardiac Auscultation Mitral Area
Apex of the heart
5th intercostal space, left midclavicular line.
The Oblique Fissure
A fissure that separates upper and lower lobes.
Starts from Rib 6 and goes up to T2-T4
The Cardiac Notch Location
5th and 6th rib on the left.
The Horizontal Fissue
On the right lung.
it lies around the 4th rib and sepearates the uppr and lower lobes of the right lung.
Does the Middle Lobe extend posteriorly?
No, it does no extend past the midaxillary line.
Right Upper Lobe
Anterior Ribs 1-4
Posterior Ribs 1-5
Right Middle Lobe
Right anterolateral to medial Ribs 4-6
Right Lower Lobe
Posterior: Ribs 6-12 with deep inspiration.
Left Upper Lobe
Anterior: Ribs 1-6
Posterior: Ribs 1-4
Left Lower Lobe
Posterior: Ribs 5-10
Diaphragm Origin and Insertion
O: Xiphoid process
lower 6 costal cartilages
anterior vertebral bodies of L/S.
I: Central Tendon
S1
The first heart sound, (lub), represents the atrioventricular (mitral and tricuspid) valves closing.
Beginning of Stytole
S2
The second heart sound, (dub), represents the semilunar (Aortic and pulmonic) valves closing.
Beginning of Diastole
Stethoscope: Diaphragm
High Frequency sounds S1 and S2
Stethoscope: Bell
Low frequency Sounds S3 and S4
S3
Associated with ventricular failur. Blood enters the ventricle during early diastole and meets a ventricle that is too compliant which creates a low frequency reverberating sound. S3 is a hallmark of congestive heart failure.
Can be heard in children, pregnant women, elderly, infections, fever, or athletes.
S3 heard just after S2
S4
Always considered to be abnormal. It is associated with MI/HTN and happens in late diastole requiring the atria to contract harder against a less compliant ventricle. The stronger atrial contraction and increased propulsion creates the sound.
S4 is often a sign of diastolic heart failure.
S4 happens just before S1
Murmurs
Vibrations resulting from turbulent blood flow. These are considered abnormal.
Pericardial Rubs
This sound resembles squeaky leather and is often described as grating or scratching.
This occurs when inflammation causes the inner (visceral) and outer (parietal) pericardial wall layers to rub against each other.
Where to listen for upper lobes.
Ribs 1-4 in the intercostal space.
Where to listen for the middle lobe on the right?
Rib 6, mid clavicular.
Where to listen to the lower lobes?
Lower lobes cannot be heard from the anterior. Must listen posteriorly.
Bronchovesicular Breath Sounds
These are breath sounds of immediate intensity and pitch.
Inspiratory and expiratory sounds are equal in both.
Best heard in the 1st and 2nd intercostal space just adjacent to the manubrium or between the scapulae. This is over the main-stem bronchi.
Vesicular Breath Sounds
This is the normal breath sound and is heard over most of the lungs. They are soft and low pitched.
Inspiratory sounds are longer and louder than expiratory sounds.
Vesicular breath sounds may be harsher and slightly longer if there is rapid deep ventilation (exercise) or in children who have thinner chest walls.
These may be softer if the patient is frail, elderly, obese or very muscular.
Hearing brochiovesicular sounds in an area where there should be vesicular sounds in indicative of pathology.
Adventitious Souns
Crackles
Wheezes
Pleural Rubs
Leather scrapping together (look at pericardial and differentiate). This occurs with inspiration and expiration.
One way to differentiate is to have the person hold their breath. If ht sound persist than it is pericardial. If it stops with the breath then it is plural.
Strydor
Upper airway obstruction
Normal Breath
12-20 breaths/min
Inhalation to Exhalation Ratio
1:2
Inhalation Step 1
Diaphragm contracts inferiorly, reflected by a subtle rise of the upp abdomen.
Inhalation Step 2
Diaphragms central tendon is stabilized by increased intra-abdominal pressure, improving the biomechanical coupling between diaphragm and intercostals as reflected by a gentle expansion laterally of the lower chest.
Inhalation Step 3
Upper accessory muscles activate to support patency of upper airways and the upper chest as reflected by a gentle rise in the upper chest primarily in the superior anterior plane.
Abnormal Inhilation
Dyspnea, excessive accessory muscle use, cyanosis of skin, lips or extremities, digital clubbing, look of apprehension, nasal flaring.
Rib Movement: Inhilation
Outward and upward.
Ribs 1-6 increase the anterior/posterior dimension of the chest, and are responsible for the pump handle action: elevation of the manubrium and sternum up and forward
Ribs 7-12 Mainly increase lateral or transverse dimension. The ribs move upward, backward and medially to increase the infrasternal angle which is called bucket handle action.
Abdominal Paradox
Upward and outward motion of the upper chest and inward motion of the abdomen.
Common with COPD
Upper Chest Paradox
Upward and outward motion of the abdomen and inward motion of the upper chest.
Common with spinal cord injuries below C5, where the diaphragm (C3-C5) is still innervated but not the respiratory intercostal muscles.
Lobe Motion, Therapist Hands
Upper: Thumbs at sternal angle with hands relaxed over the clavicle and upper traps.
Right middle and Left Lingual: Thumbs over xiphoid process with hands under breast.
Lower Lobe: Palpating posteriorly, with hand and thumbs on either side of the Thoracic Vertabra.
Objective Chest Wall Excursion Assessment
Using a tape measure the differences between rest and full max inhilation at the:
Sternal angle
Xiphoid process
Midway between xiphoid process & umbillicus ( should be between 5-8.5)
Mediate Percussion
Used to evaluate for changes in lung density. The technique is performed to assess for lung consolidation versus hyper inflation and can also be used to assess for diaphragmatic excursion.
Resonant Sounds
Loud or high amplitude, low pitch, longer duration, heard over air filled organs like the lungs.
Dull Sounds
Low amplitude, medium to high pitch, short duration; heard over solid organs such as the liver.
Egophony
Also used to assess lung densities.
Pt says E. If pathology is present (Pneumonia); the auscultated sound will be and A.
Increased air, hyper inflation lung pathologies, decreases sound transmission.
Lung pathologies that are characterized by increased consolidation will have increased/ amplified sound transmission (whales)
Bronchophony
Also used to assess lung densities.
Pt says 99 out loud. If pathology (consolidation) is present, the auscultated sound will be amplified and heard more clearly over the entire chest. Conversely if a hyper-inflated pathology is present, the auscultated sound will be softer and muffled.
Whispering Pectoriloquy
Also used to assess lung densities.
Pt whispers 99. If pathology is present; the sound will be distinctly and clearly heard through the stethoscope.
This is especially useful for patients with vocal cord dysfunction.
Tactile Fremitus
Also used to assess lung densities.
Fremitus is a palpable vibratory sensation to the chest wall from lung tissue.
PT places ulnar border of hand on either side of the chest while the pt says 99. This maneuver is repeated until the entire posterior thorax is covered.
Increased Fremitus = increased consolidation or secretions in that area.
Deceased Fremitus = increased air in that area (hyper-inflation)>
Atelectasis
Collapse or closure of a lung.
