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History & Physical Examination > Exam 1 - Thorax and Lungs Physical Exam > Flashcards

Exam 1 - Thorax and Lungs Physical Exam Flashcards

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1
Q

2nd intercostal space

A

Needle insertion/ decompression of tension PTX

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2
Q

4th intercostal space

A

Chest tube insertion

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3
Q

When you document your findings in thorax, how are they described? What two dimensions?

A

The vertical axis and circumferentially.

To denote vertical locations, count the ribs and interspaces; sternal angle is the best guide!

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4
Q

To denote findings around the circumference of the thorax, imagine a series of vertical lines. Name them!

A

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.

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5
Q

How is the left lung divided?

A

The left lung is divided into upper and lower lobes

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6
Q

How is the right lung divided?

A

The right lung is divided into upper, middle, and lower lobes

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7
Q

What is the oblique or major lung fissure?

A

Each lung is divided roughly in half by an oblique (major) fissure

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8
Q

What is a minor lung fissure?

A

The right lung is further divided by the horizontal (minor) fissure; only present in right lung! Bc right lung has three lobes

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9
Q

Where does the trachea branch?

A

The trachea bifurcates at sternal notch (anteriorly), and T4 (posteriorly).

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10
Q

Supraclavicular

A

Above the clavicles

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11
Q

Infraclavicular

A

Below the clavicles

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12
Q

Interscapular

A

Between the scapulae

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13
Q

Infrascapular

A

Below the scapulae

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14
Q

Bases of the lungs

A

The inferior-most portions

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15
Q

Apices of the lungs

A

The superior-most portions

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16
Q

Common Complaints of Thorax/Lungs

A 
Chest pain
Shortness of breath
Wheezing
Cough
Blood-streaked sputum
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17
Q

When a patient has chest pain, it is EXTREMELY important that you:

A

Ask the patient to point to the location of the pain

Attempt to elicit all seven attributes of the patient’s symptom

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18
Q

Chest pain is complicated because:

A

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?

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19
Q

How to ask about Shortness of Breath (Dyspnea)?

How do you determine severity?

A

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.

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20
Q

What is wheezing?

A

Wheezes are musical respiratory sounds that may be audible to the patient and to others

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21
Q

What do you ask when your patient has a cough?

A
  1. Ask whether the cough is dry or produces sputum, or phlegm
  2. Ask the patient to describe the volume of any sputum and its color, odor, and consistency
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22
Q

What is a cough?

A

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.

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23
Q

What is Hemoptysis?

A

Hemoptysis is the coughing up of blood from the lungs; it may vary from blood-streaked phlegm to frank blood

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24
Q

What do you ask when a patient has hemoptysis?

A

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

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25
Q

Tobacco cessation is the leading cause of _____.

A

Smoking is the leading cause of preventable death in the United States

26
Q

Remember the 5 A’s that regard smoking addiction.

A

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

27
Q

Who should get a pneumococcal vaccine?

A

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).

28
Q

Who should get an influenza vaccine?

A

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

29
Q

Respiratory ROS

A 
Cough
Sputum (color, quantity)
Dyspnea
Hemoptysis
Wheezing
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Pleurisy
Last CXR
30
Q

General Technique of Lung and Thorax Exam

A

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

31
Q

Inspection of Lungs/Thorax

A

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

32
Q

Chest Expansion

A

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

33
Q

Tactile Frenitus

A

Note tactile fremitus = palpable vibrations as the patient is speaking; ask the patient to say “99”

34
Q

Percussion of Thorax

A

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

35
Q

Pleximeter

A

Finger that dips in contact with chest during percussion

36
Q

Plexor

A

Finger that taps for percussion

37
Q

Why is percussion useful?

A

Percussion helps establish whether the underlying tissues (5-7 cm deep) are air-filled, fluid-filled, or solid

38
Q

Flat sounds from percussion

A

Flat sounds - fluid consolidation, such as a large pleural effusion — usually blood, mucus, fluid

39
Q

Dull sounds from percussion (decrease of resonance)

A

Dull sounds = a solid sound, such as the liver, lobar pneumonia
Dull=SOLID - diaphragm in diaphragmatic excursion has a DULL sound.

40
Q

Resonant Sounds from percussion

A

Resonant sounds = a loud, clear, deep sound, such as with normal lungs, simple bronchitis

41
Q

Hyperresonant sounds from percussion

A

Hyperresonant sounds = exaggerated lung sounds, such as with abnormal pulmonary conditions (COPD)

42
Q

Tympanic sounds from percussion

A

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).

43
Q

Bell of stethoscope

A

Picks up low pitch, ex: bruits and heart murmurs

44
Q

Diaphragm of stethoscope

A

Picks up higher pitched sounds

45
Q

Auscultation of the chest

A

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

46
Q

Normal breath sounds: Vesicular sounds

A

Vesicular = SOFT and low pitched; usually heard over most of both lungs

47
Q

Normal breath sounds: Bronchial sounds

A

Bronchial = LOUD and higher in pitch; usually heard over the manubrium

48
Q

Normal breath sounds: Bronchovesicular

A

Bronchovesicular = INTERMEDIATE intensity and pitch; usually heard over the 1st and 2nd interspaces

49
Q

What are the three types of normal sounds when auscultating the lungs?

A

Vesicular sounds, bronchial sounds, and bronchovesicular sounds

50
Q

What are adventitious sounds?

A

Adventitious sounds = added sounds

Crackles, wheezes, and rhonchi

51
Q

What are three examples of adventitious sounds?

A

Crackles, wheezes, and rhonchi

52
Q

What is consolidation of the lungs?

A

Consolidation = increased tissue density due to being filled with blood, fluid, mucous

53
Q

What are the special tests for lungs when consolidation is suspected?

A

Egophony, bronchophony, whispered pectoriloquy, diaphragmatic excursion

54
Q

Special Test: Broncophony

A

Bronchophony
“99” while auscultating, “normal” should sound muffled or indistinct
If loud = (+) bronchophony

55
Q

Special Test: Egophony

A

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

56
Q

Special Test: Whispered Pectoriloquy

A

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

57
Q

Special test: Diaphragmatic Excursion

A

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

58
Q

Thorax Doc EX

A

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.

59
Q

What does lung tissue lack?

A

Lung tissue itself has no pain fibers; pain in lung conditions usually arises from inflammation of the adjacent parietal pleura

60
Q

Pleural effusion

A

abnormal amount of fluid around the lung

History & Physical Examination (19 decks)

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