Exam 1 - Thorax and Lungs Physical Exam Flashcards
2nd intercostal space
Needle insertion/ decompression of tension PTX
4th intercostal space
Chest tube insertion
When you document your findings in thorax, how are they described? What two dimensions?
The vertical axis and circumferentially.
To denote vertical locations, count the ribs and interspaces; sternal angle is the best guide!
To denote findings around the circumference of the thorax, imagine a series of vertical lines. Name them!
ANTERIOR VIEW: Midsternal line, midclavicular line, anterior axillary line
LATERAL VIEW: Anterior axillary line, medial axillary line, posterior axillary line
POSTERIOR VIEW: Vertebral line in middle and scapular line in the middle of the scapula.
How is the left lung divided?
The left lung is divided into upper and lower lobes
How is the right lung divided?
The right lung is divided into upper, middle, and lower lobes
What is the oblique or major lung fissure?
Each lung is divided roughly in half by an oblique (major) fissure
What is a minor lung fissure?
The right lung is further divided by the horizontal (minor) fissure; only present in right lung! Bc right lung has three lobes
Where does the trachea branch?
The trachea bifurcates at sternal notch (anteriorly), and T4 (posteriorly).
Supraclavicular
Above the clavicles
Infraclavicular
Below the clavicles
Interscapular
Between the scapulae
Infrascapular
Below the scapulae
Bases of the lungs
The inferior-most portions
Apices of the lungs
The superior-most portions
Common Complaints of Thorax/Lungs
Chest pain Shortness of breath Wheezing Cough Blood-streaked sputum
When a patient has chest pain, it is EXTREMELY important that you:
Ask the patient to point to the location of the pain
Attempt to elicit all seven attributes of the patient’s symptom
Chest pain is complicated because:
Aside from lung conditions, chest pain may arise from cardiac, vascular, gastrointestinal, musculoskeletal, or skin pathology; it is also commonly associated with anxiety!
Other surrounding structures may also irritate the parietal pleura, causing pain.
**Difficult to find source?
How to ask about Shortness of Breath (Dyspnea)?
How do you determine severity?
Dyspnea is not painful, but an uncomfortable awareness of breathing that is inappropriate to the level of exertion.
Begin assessment with a broad question, such as, “Have you had any difficulty breathing?”
Determine the severity of dyspnea based on the patient’s daily activities = dyspnea on exertion.
What is wheezing?
Wheezes are musical respiratory sounds that may be audible to the patient and to others
What do you ask when your patient has a cough?
- Ask whether the cough is dry or produces sputum, or phlegm
- Ask the patient to describe the volume of any sputum and its color, odor, and consistency
What is a cough?
Cough is typically a reflex response to stimuli that irritate receptors in the larynx, trachea, or large bronchi; it may sometimes be cardiovascular in origin.
What is Hemoptysis?
Hemoptysis is the coughing up of blood from the lungs; it may vary from blood-streaked phlegm to frank blood
What do you ask when a patient has hemoptysis?
Ask the patient to describe the volume of blood produced as well as other sputum attributes
Try to confirm the source of the bleeding by history and examination before using the term “hemoptysis”; blood may also originate from the mouth, pharynx, or gastrointestinal tract
Tobacco cessation is the leading cause of _____.
Smoking is the leading cause of preventable death in the United States
Remember the 5 A’s that regard smoking addiction.
ASK, ADVISE, ASSESS, ASSIST, ARRANGE
Ask about smoking at each visit
Advise patients regularly to stop smoking using a clear, personalized message
Assess patient readiness to quit
Assist patients to set stop dates and provide educational materials for self-help
Arrange for follow-up visits to monitor and support patient progress
Who should get a pneumococcal vaccine?
Adults ≥65 years
◗ Children and adults from 2 years to 64 years old with chronic illnesses spe- ci cally associated with increased risk of pneumococcal infection (sickle cell anemia, cardiovascular and pulmonary disease, diabetes, cirrhosis, and leaks of cerebrospinal uid)
◗ Smokers from 19 years to 64 years old
◗ Anyone with or about to receive a cochlear implant
◗ Adults and children older than 2 years who are immunocompromised
(including from HIV infection, AIDS, steroids, radiation, or chemo).
Who should get an influenza vaccine?
Adults with chronic pulmonary conditions, those immunosuppressed or morbidly obese, chronic med conditions
◗ Health care personnel
◗ pregnant women (pregnant during flu season)
◗ Residents of nursing homes
◗ American Indians and Alaska natives
Household contacts and caregivers of children 5 years of age and younger (especially infants age 6 months and younger) and of adults 50 years of age and older with medical conditions placing them at higher risk for complications of influenza
Respiratory ROS
Cough Sputum (color, quantity) Dyspnea Hemoptysis Wheezing Asthma Bronchitis Emphysema Pneumonia Tuberculosis Pleurisy Last CXR
General Technique of Lung and Thorax Exam
Examine the anterior and posterior thorax and lungs while the patient is sitting
May also examine the anterior thorax and lungs with the patient laying supine
Compare one side of the thorax and lungs with the other
Proceed in an orderly fashion: inspect, palpate, percuss, and auscultate
Inspection of Lungs/Thorax
Initial survey of respiration and the thorax
Observe the rate, rhythm, depth, and effort of breathing
Inspect for any signs of respiratory difficulty
Patient’s color (pale, cyanotic), patient’s breathing (labored, retractions, use of accessory muscles, pursed lips)
Inspect the patient’s neck (distended veins, use of accessory muscles)
Inspect the shape of the chest
AP diameter (increases with age) vs Lateral diameter
Chest Expansion
Test chest expansion: place thumbs at the level of the 10th rib with fingers loosely grasping and parallel to the lateral rib cage; watch the distance between the thumbs as they move apart during deep inspiration
Tactile Frenitus
Note tactile fremitus = palpable vibrations as the patient is speaking; ask the patient to say “99”
Percussion of Thorax
Percussion - Perform from side to side to assess for asymmetry
Strike using the tip of your tapping finger
Use middle finger of one hand (pleximeter), only DIP in contact with chest
Use middle finger tip on other hand (plexor), 90 deg angle to pleximeter
Use the lightest percussion that produces a clear note
Pleximeter
Finger that dips in contact with chest during percussion
Plexor
Finger that taps for percussion
Why is percussion useful?
Percussion helps establish whether the underlying tissues (5-7 cm deep) are air-filled, fluid-filled, or solid
Flat sounds from percussion
Flat sounds - fluid consolidation, such as a large pleural effusion — usually blood, mucus, fluid
Dull sounds from percussion (decrease of resonance)
Dull sounds = a solid sound, such as the liver, lobar pneumonia
Dull=SOLID - diaphragm in diaphragmatic excursion has a DULL sound.
Resonant Sounds from percussion
Resonant sounds = a loud, clear, deep sound, such as with normal lungs, simple bronchitis
Hyperresonant sounds from percussion
Hyperresonant sounds = exaggerated lung sounds, such as with abnormal pulmonary conditions (COPD)
Tympanic sounds from percussion
Tympanic sounds = absent sounds, such as a large PTX (from air filling the chest cavity in front of the lungs which causes lung to collapse).
Bell of stethoscope
Picks up low pitch, ex: bruits and heart murmurs
Diaphragm of stethoscope
Picks up higher pitched sounds
Auscultation of the chest
The most important examination technique for assessing air flow through the tracheobronchial tree (and surrounding lungs/pleura)
Listen to the breath sounds with the diaphragm of a stethoscope after instructing the patient to breathe deeply through an open mouth
Use the same pattern as for percussion, moving from one side to the other and comparing symmetric areas of the lungs
Listen to at least one full breath in each location
Do not move stethoscope until patient fully exhales
Normal breath sounds: Vesicular sounds
Vesicular = SOFT and low pitched; usually heard over most of both lungs
Normal breath sounds: Bronchial sounds
Bronchial = LOUD and higher in pitch; usually heard over the manubrium
Normal breath sounds: Bronchovesicular
Bronchovesicular = INTERMEDIATE intensity and pitch; usually heard over the 1st and 2nd interspaces
What are the three types of normal sounds when auscultating the lungs?
Vesicular sounds, bronchial sounds, and bronchovesicular sounds
What are adventitious sounds?
Adventitious sounds = added sounds
Crackles, wheezes, and rhonchi
What are three examples of adventitious sounds?
Crackles, wheezes, and rhonchi
What is consolidation of the lungs?
Consolidation = increased tissue density due to being filled with blood, fluid, mucous
What are the special tests for lungs when consolidation is suspected?
Egophony, bronchophony, whispered pectoriloquy, diaphragmatic excursion
Special Test: Broncophony
Bronchophony
“99” while auscultating, “normal” should sound muffled or indistinct
If loud = (+) bronchophony
Special Test: Egophony
Egophony
Have patient say “EE” while auscultating
“Normal” should sound like a muffled, long “E” sound
If it sounds like “A”, then there is an E to A change = (+) egophany
Special Test: Whispered Pectoriloquy
Whispered Pectoriloquy
Have the patient whisper “99” as you auscultate
Normally the “99” is faintly heard, indistinctly heard, or not heard at all
If the “99” is louder and clearer = (+) whispered pectoriloquy
Special test: Diaphragmatic Excursion
Diaphragmatic Excursion
Movement of the diaphragm during breathing
Percuss to find border of resonant to dull
That is the diaphragm
Mark this
Have the patient inhale and hold breath
Percuss from that mark until you find dullness again
Normal 3-5 cm excursion
Thorax Doc EX
Thorax is symmetric with good expansion. Lungs resonant. Bilateral breath sounds vesicular; no rales, wheezes, or rhonchi. Diaphragm descends 4cm bilaterally.
Lungs CTA bilaterally. No crackles, wheezes or rhonchi bilaterally.
Thorax symmetric with moderate kyphosis and increased anteroposterior (AP) diameter, decreased expansion. Lungs are hyperresonant. Breath sounds distant with delayed expiratory phase and scattered expiratory wheezes. Fremitus decreased; no bronchophony, egophony, or whispered pectoriloquy. Diaphragm descends 2 cm bilaterally.
What does lung tissue lack?
Lung tissue itself has no pain fibers; pain in lung conditions usually arises from inflammation of the adjacent parietal pleura
Pleural effusion
abnormal amount of fluid around the lung
