Exam #3: Chest, Thorax, & Lungs Flashcards
How do you describe chest findings?
- Along the vertical axis
- Around the circumference of the chest
Midclavicular Line
- Drops vertically from the midpoint of the clavicle
Anterior & Posterior Axillary Lines
- Anterior drops from the anterior axillary fold
- Posterior drops from the posterior axillary fold
Midaxillary Line
Drops from the apex of the axilla
Vertebral Line
Overlies the spinous processes of the vertebrae
Scapular Line
Drops from the inferior angle of the scapula
Apex of the Lung
2-4cm above the inner 1/3 of the clavicle
Inferior Border of Lung
Anterior= 6th rib, midclavicular line Lateral= 8th rib, mixaxillary line Posterior= T10
Drops further on inspiration (roughly 4cm)
Oblique Fissure (Lung)
- Divides the lungs into anterior and posterior halves
- T3 spinous process–>6th rib at the midclavicular line
- Both lungs
Horizontal Fissure (Lung)
- Divides the right lung into superior & inferior halves or thirds
- 4th rib at the sternum–>5th rib at the midaxillary line
- RIGHT lung only
Right Lung # Lobes
Three: upper, middle, & lower
Left Lung # Lobes
Two: upper & lower
Where does the trachea divide into mainstem bronchi?
Anterior= Sternal Angle Posterior= T4
Visceral Pleura
Covers the outer surface of the lung
Parietal Plerua
Lines the inner rib cage & upper surface of the diaphragm
Into which mainstem bronchi is foreign body aspiration more common & why?
Right b/c it is straighter, wider, & shorter than the left
Principal Muscles of Inspiration
- Diaphragm
- Intercostals (External & Interchondral part of Internal)
Accessory Muscles of Inspiration
- SCM
- Scalenes
Muscles of Active Expiration
- Internal Intercostals (except interchondral part)
- Abdominal Muscles
Common or Concerning Symptoms
- Chest pain
- Dyspnea
- Wheezing
- Cough
- Hemoptysis
What is key in obtaining a history or assessment of a patient complaining of chest pain or dyspnea?
General impression or the apparent stability of the patient
Cardiac Causes of Chest Pain
1) Myocardium: angina pectoris, MI, myocarditis
2) Pericardium: pericarditis
3) Aorta: Dissecting aortic aneurysm
Pulmonary Causes of Chest Pain
1) Trachea & Large Bronchi: Bronchitis
2) Parietal Pleura: Percarditis, pneumonia, pneumothorax, pleural effusion, PE
“Other Causes of Chest Pain”
1) Chest Wall: Costochondritis, Herpes Zoster
2) Esophagus: Reflux esophagitis, esophageal spasm, esophageal tear
3) Extrathoracic: Cervical Arthritis, Biliary Colic, Gastritis
Important Characteristics of Breathing
- Rate (14-20 is normal)
- Rhythm
- Depth
- Effort
Dyspnea Differential
- Lung= COPD, Pneumonia, Asthma, Acute Bronchitis, PE, Pneumothorax
- Other= Chest Wall, Compression Fracture, Phrenic Nerve, Central or Peripheral Neurologic, Psychologic (Anxiety), Systemic, MI, Epigastric
What is the chief goal when obtaining a history from a dyspneic patient?
- Stability
- Determining the severity based on the patient’s daily activities
Wheezing/ Coughing/ Hemoptysis Differential
- Lung= Cancer, COPD, Pneumonia, Asthma, Acute Bronchitis
- Nose & Mouth= Allergic Rhinitis, Aspiration, Irritant
- Stomach= GERD, Bulimia, Cyclic Vomiting Syndrome
- Other= Phrenic Nerve, Central or Peripheral Neurologic, Psychologic (Habit Cough, Chronic Throat Clearing), Systemic (Bleeding Problem)
What is increased tactile fremitus a sign of?
Fluids, secretion, or a solid mass in the lung
What is decreased tactile fremitus a sign of?
Excess air in the lungs
Resonant percussion tone
- Loud
- Low pitched
- Long
- Hollow
Flat percussion tone
- Soft
- High pitched
- Short
- Very dull
Dull percussion tone
- Medium
- Medium to high pitched
- Medium duration
- Dull-thud in quality
Tympanic percussion tone
- Loud
- High pitched
- Medium duration
- Drum-like
Hyperresonant percussion tone
- Very loud
- Very low pitched
- Long
- Booming
Diaphragmatic Excursion Technique
1) Find lower border of lung w/ percussion first, bilaterally
2) Percuss the lower border after exhalation
Normal is 3-5cm (also, note that the diaphragm is higher on the right due to the liver)
Vesicular Breath Sounds
- Inspiration longer than expiration
- Inspiration louder than expiration
- No gap between inspiration & expiration
- Heard best in the bases of the lungs
- Normal
Bronchial Breath Sounds
- Louder than vesicular breath sounds
- Inspiration & expiration same loudness
- Inspiration & expiration same duration
- Gap between inspiration & expiration
- SHOULD NOT be heard in the normal lung parenchyma
What causes bronchial sounds in the normal lung parenchyma?
- Consolidated lung of pneumonia
- Atelectasis
- Pulmonary mass
Crackles
Caused by disruption of air passage through small airways & do not clear with coughing
- Heard during inspiration
- Discontinuous
- Short Duration
- Formerly rales
Rhonchi
A deeper rumbling that is continuous and prolonged.
- Usually heard during expiration
- Suggest airway obstruction by thick secretions, muscle spasm, or external pressure
Wheezes
A high pitched musical sound
- Often heard continuously during inspiration & expiration
- Higher pitch= worse obstruction
Bronchophony
- Tested by having the patient say 99
- LOUDER= abnormal & indicates the presence of a consolidation
Egophony
- Tested by having the patient say E
- “ee” transitioning to “ay”= ABNORMAL & indicates consolidation
Pectoriloquy
- Tested by having the patient whisper 1,2,3
- LOUD & CLEAR= abnormal & indicates consolidation
Cheyne Stokes
- Alternating periods of apnea & hyperpnea
- Can be normal during sleep & at high altitude
- 30% due to CHF
- Also neurologic disorders & TBI
Kussmal’s
- Very deep
- Rapid
- Gasping
- Seen in metabolic acidosis
Grunting
- Short & explosive sounds
- Common in children, indicates respiratory fatigue in adults
- Attempt to slow expiration & allow maximal gas exchange
Adventitious Breath Sounds
Abnormal auscultated breath sounds e.g. crackles, rhonchi, wheezes & friction rub
Apnea
Halt to breathing
Asthma
Small airway obstruction caused by inflammation and hyperactive airways
Atelectasis
Incomplete expansion of the lung
Barrel Chest
Increased anteroposterior diameter of the chest, often with some degree of kyphosis; commonly seen in COPD
Biot Respirations
Irregular respirations varying in depth and interrupted by intervals of apnea that lacks repetitive pattern
Bronchiectasis
Chronic dilation of the bronchi or bronchioles caused by repeated infections of bronchial obstructions
Bronchitis
Inflammation of the large airways
Bronchiolitis
Inflammation of the bronchioles
COPD
Disease process which causes decreased ability of the lungs to perform their function of ventilation
Tubular Breath Sounds
- Heard only over the trachea
- High pitch
- Loud & long expirations
Bronchovesicular Breath Sounds
- Heard over main bronchus area & right posterior lung field
- Medium pitch
- Expiration equals inspiration
Pectus Carinatum
Forward protrusion of the chest commonly referred to as a Pigeon Chest
Pectus Excavatum
Depression of the sternum commonly called a Funnel Chest
